Healthcare Provider Details

I. General information

NPI: 1891380432
Provider Name (Legal Business Name): MIDWEST CARDIOVASCULAR RESEARCH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E 4TH ST STE A
DAVENPORT IA
52801-1713
US

IV. Provider business mailing address

PO BOX 850
MOLINE IL
61266-0850
US

V. Phone/Fax

Practice location:
  • Phone: 563-324-2828
  • Fax:
Mailing address:
  • Phone: 309-762-9711
  • Fax: 309-764-0553

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 Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLAS SHAMMAS
Title or Position: OWNER
Credential: MD
Phone: 563-320-0263