MEDICARE: RUSSELLVILLE CARDIOLOGY CONSULTANTS, PA

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	207RC0000X	Cardiovascular Disease Physician	E5291	AR

General Provider Information

NPI Number	:	1205076387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELLVILLE CARDIOLOGY CONSULTANTS, PA

Provider Business Mailing Address
First Line	:	106 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-4311
Fax Number	:	479-968-4399

Provider Business Practice Location Address
First Line	:	106 S INGLEWOOD AVE
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-3353
Country	:	US
Telephone Number	:	479-968-4311
Fax Number	:	479-968-4399

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAI YUAN WANG
Credential	:	MD
Telephone Number	:	479-968-4311

Provider Enumeration Date	:	03/02/2009
Last Update Date	:	03/13/2009

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