Healthcare Provider Details

I. General information

NPI: 1376715458
Provider Name (Legal Business Name): ADVANCED CARDIAC SPECIALISTS, CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 WILLOW CREEK RD SUITE 201
PRESCOTT AZ
86301-1611
US

IV. Provider business mailing address

PO BOX 63423
PHOENIX AZ
85082-3423
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-4142
  • Fax: 480-982-1400
Mailing address:
  • Phone: 480-892-2800
  • Fax: 480-288-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateAZ

VIII. Authorized Official

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