Healthcare Provider Details

I. General information

NPI: 1841650850
Provider Name (Legal Business Name): CARDIAC CATH LAB OF PHOENIX, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 E THOMAS RD SUITE 101
PHOENIX AZ
85016-7766
US

IV. Provider business mailing address

1910 E THOMAS RD SUITE 101
PHOENIX AZ
85016-7766
US

V. Phone/Fax

Practice location:
  • Phone: 713-812-7586
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: GREGG MILLER
Title or Position: SR. VICE PRESIDENT
Credential: MD
Phone: 610-644-8900