Healthcare Provider Details

I. General information

NPI: 1235130824
Provider Name (Legal Business Name): ADVANCED CARDIAC SPECIALISTS, CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4838 E BASELINE RD BLDG. 2 STE. 110
MESA AZ
85206-4671
US

IV. Provider business mailing address

PO BOX 63423
PHOENIX AZ
85082-3423
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-2800
  • Fax: 480-982-1400
Mailing address:
  • Phone: 480-892-2800
  • Fax: 480-982-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17159
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number16175
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number30602
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number30602
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM FAZIO
Title or Position: CONTROLLER
Credential:
Phone: 480-545-1808