=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285805879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOVASCULAR DISEASES OF NILES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2008
-----------------------------------------------------
Last Update Date | 05/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 N SAINT JOSEPH AVE SUITE A
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49120-2263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-683-1120
-----------------------------------------------------
Fax | 269-683-4325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 N SAINT JOSEPH AVE SUITE A
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49120-2263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-683-1120
-----------------------------------------------------
Fax | 269-683-4325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MUNDATHAJE ISHWARA BHAT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 269-683-1120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 42240
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------