=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295003408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAYETTE SPECIALTY ASSOCIATES CARDIOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2011
-----------------------------------------------------
Last Update Date | 12/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 MARY HIGGINSON LN SUITE 2
-----------------------------------------------------
City | UNIONTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15401-2658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-437-7073
-----------------------------------------------------
Fax | 724-437-4636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 YOUNGSTOWN RD SUITE 102
-----------------------------------------------------
City | LEMONT FURNACE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15456-1344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-425-8334
-----------------------------------------------------
Fax | 724-434-1659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | DANIELLE PRICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-425-8318
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------