Healthcare Provider Details

I. General information

NPI: 1396719480
Provider Name (Legal Business Name): INTERVENTIONAL CARDIOLOGY MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 MEDICAL CENTER DR STE 201
WEST HILLS CA
91307-1935
US

IV. Provider business mailing address

7301 MEDICAL CENTER DR STE 201
WEST HILLS CA
91307-1935
US

V. Phone/Fax

Practice location:
  • Phone: 818-702-8800
  • Fax: 818-702-0080
Mailing address:
  • Phone: 818-702-8800
  • Fax: 818-702-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: LACIE CONNOLLY
Title or Position: DIRECTOR OF OPERATIONS & DEVLOPMENT
Credential:
Phone: 818-702-8800