Healthcare Provider Details

I. General information

NPI: 1770501256
Provider Name (Legal Business Name): CARDIAC CARE CONSULTANTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 45TH AVE
MUNSTER IN
46321-3915
US

IV. Provider business mailing address

1730 45TH AVE
MUNSTER IN
46321-3915
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-9677
  • Fax: 219-836-0688
Mailing address:
  • Phone: 219-836-9677
  • Fax: 219-836-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number01040667
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number01042616
License Number StateIN

VIII. Authorized Official

Name: LOURDES CANELAS
Title or Position: ADMINISTRATION
Credential:
Phone: 219-836-9677