MEDICARE: LAKESIDE HEART AND VASCULAR CENTER 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	44211	AZ
2	207RI0011X	Interventional Cardiology Physician	44211	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P-1663566-8	OTHER	AZ	ARIZONA CORPORATION COMMISSION FILING NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801194352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE HEART AND VASCULAR CENTER PLLC

Provider Business Mailing Address
First Line	:	PO BOX 3539
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-3539
Country	:	US
Telephone Number	:	928-453-2727
Fax Number	:	928-453-2828

Provider Business Practice Location Address
First Line	:	1741 MESQUITE AVE
Second Line	:	SUITE A100
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5695
Country	:	US
Telephone Number	:	928-453-2727
Fax Number	:	928-453-2828

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	FADI ATASSI
Credential	:	M.D.
Telephone Number	:	928-453-2727

Provider Enumeration Date	:	03/08/2011
Last Update Date	:	07/20/2011

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