=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356712848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOVASCULAR SOLUTIONS OF CENTRAL MS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2015
-----------------------------------------------------
Last Update Date | 04/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 N PEARMAN AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38732-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-757-0838
-----------------------------------------------------
Fax | 888-796-1835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 N PEARMAN AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38732-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-757-0838
-----------------------------------------------------
Fax | 888-796-1835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | FOLUSO A FAKOREDE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 888-757-0838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------