Healthcare Provider Details

I. General information

NPI: 1962283887
Provider Name (Legal Business Name): CS CARDIOLOGY NEWCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 PHAY AVE
CANON CITY CO
81212-2311
US

IV. Provider business mailing address

1338 PHAY AVE
CANON CITY CO
81212-2311
US

V. Phone/Fax

Practice location:
  • Phone: 719-960-0363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIN PETRIE
Title or Position: VP OF RCM
Credential:
Phone: 708-498-4493