=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326093964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGIONAL CARDIOLOGY ASSOCIATES, P.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 03/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5625 WATER TOWER PL
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346-2671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-620-4270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3399 POLLOCK RD
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-8393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-603-0170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MRS. LINDA SANDERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-603-0170
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 7100B51074
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------