=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104434356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME HEART AND VASCULAR CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2020
-----------------------------------------------------
Last Update Date | 07/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1310 HIGHWAY 72 E
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38834-6524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-201-2307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1470
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38835-1470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-201-2307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | MANDAR R JAGTAP
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 317-201-2307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------