Medical School Information |
|
Medical School Name
|
OTHER
|
|
Individual professional's medical school
|
|
Graduation Year
|
1988
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
CARDIOVASCULAR DISEASE (CARDIOLOGY)
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
INTERNAL MEDICINE
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 2
|
PERIPHERAL VASCULAR DISEASE
|
|
Second secondary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 3
|
VASCULAR SURGERY
|
|
Third secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
INTERNAL MEDICINE, PERIPHERAL VASCULAR DISEASE, VASCULAR SURGERY
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
ALLEN COUNTY CARDIOLOGY, LLC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
9133290752
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
2
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
2120 N DETROIT ST
|
|
Group Practice or individual's line 1 address
|
|
Line 2 Street Address
|
ALLEN COUNTY CARDIOLOGY
|
|
Group Practice or individual's line 2 address
|
|
City
|
LA GRANGE
|
|
Group Practice or individual's city
|
|
State
|
IN
|
|
Group Practice or individual's state
|
|
Zip Code
|
467611147
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
2604692468
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
151315
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
CAMERON MEMORIAL COMMUNITY HOSPITAL INC
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
150017
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
LUTHERAN HOSPITAL OF INDIANA
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
150047
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
ST JOSEPH HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Hospital Affiliation CCN 4
|
150021
|
|
Medicare CCN of hospital where individual professional provides service 4
|
|
Hospital Affiliation LBN 4
|
PARKVIEW REGIONAL MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 4
|
|
Hospital Affiliation CCN 5
|
150150
|
|
Medicare CCN of hospital where individual professional provides service 5
|
|
Hospital Affiliation LBN 5
|
DUPONT HOSPITAL LLC
|
|
Legal business name of hospital where individual professional provides service 5
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|