Healthcare Provider Details

I. General information

NPI: 1083696793
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 LAUREL ST SUITE 2200
DES MOINES IA
50314-3034
US

IV. Provider business mailing address

330 LAUREL ST SUITE 2200
DES MOINES IA
50314-3034
US

V. Phone/Fax

Practice location:
  • Phone: 515-288-1097
  • Fax: 515-288-2847
Mailing address:
  • Phone: 515-288-1097
  • Fax: 515-288-2847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BASAVIAH CHANDRAMOULI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 515-288-1097