MEDICARE: STAR STATE HEART PLLC

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	G6655	TX
2	207RI0011X	Interventional Cardiology Physician	G6655	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	TXB144746	OTHER	TX	MEDICARE
4	TXB144747	OTHER	TX	MEDICARE
5	8F24108	OTHER	TX	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477884740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STAR STATE HEART PLLC

Provider Business Mailing Address
First Line	:	PO BOX POX # 731393
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-1393
Country	:	US
Telephone Number	:	512-263-0123
Fax Number	:	512-367-5841

Provider Business Practice Location Address
First Line	:	200 MEDICAL PKWY
Second Line	:	SUITE 270
City	:	LAKEWAY
State	:	TX
Zip	:	78738-1782
Country	:	US
Telephone Number	:	512-263-0123
Fax Number	:	512-367-5841

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SAMUEL J. DEMAIO
Credential	:	M.D.
Telephone Number	:	512-263-0123

Provider Enumeration Date	:	01/26/2010
Last Update Date	:	11/08/2012

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Directions to “STAR STATE HEART PLLC ” Practice Location

Language	Start Address	Practice Location

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