MEDICARE: HEART ASSOCIATES OF SOUTH ARKANSAS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	E0097	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5C008	OTHER	AR	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073688511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART ASSOCIATES OF SOUTH ARKANSAS, INC.

Provider Business Mailing Address
First Line	:	619 W GROVE ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4413
Country	:	US
Telephone Number	:	870-863-6133
Fax Number	:	870-863-6290

Provider Business Practice Location Address
First Line	:	619 W GROVE ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4413
Country	:	US
Telephone Number	:	870-863-6133
Fax Number	:	870-863-6290

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALDO V FONTICIELLA
Credential	:	MD
Telephone Number	:	870-866-9450

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	04/10/2018

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