Basic Information
| Provider Information | |||||||||
| NPI: | 1376686311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HEART SPECIALISTS, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 743 E. BROADWAY | ||||||||
| Address2: | #300 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025843200 | ||||||||
| FaxNumber: | 5025843333 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025843200 | ||||||||
| FaxNumber: | 5025843333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | VILLAFANE | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5025843200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 24893 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 64248933 | 05 | KY | MEDICAID | 100020940 | 05 | IN | MEDICAID | 1052899 | 01 | KY | PASSPORT | OTHER |