=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982288049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOVASCULAR INTERVENTIONAL SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2021
-----------------------------------------------------
Last Update Date | 05/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2621 S BRISTOL ST STE 108B
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92704-5718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-754-1684
-----------------------------------------------------
Fax | 714-966-0417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2621 S BRISTOL ST STE 108B
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92704-5718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-754-1684
-----------------------------------------------------
Fax | 714-966-0417
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANIL V SHAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 714-290-5322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------