Healthcare Provider Details

I. General information

NPI: 1821369307
Provider Name (Legal Business Name): MIDWEST CARDIOVASCULAR CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2012
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 RALSTON AVE SUITE 203A
DEFIANCE OH
43512-5311
US

IV. Provider business mailing address

1250 RALSTON AVE SUITE 203A
DEFIANCE OH
43512-5311
US

V. Phone/Fax

Practice location:
  • Phone: 419-783-6895
  • Fax: 419-782-4459
Mailing address:
  • Phone: 419-783-6895
  • Fax: 419-782-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: AMY L BAHNSEN
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 419-824-7334