Basic Information
| Provider Information | |||||||||
| NPI: | 1386700565 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONGENITAL HEART SURGERY CENTER PLLC | ||||||||
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| Address1: | PO BOX 402018 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 6153737651 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | B-115 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725662525 | ||||||||
| FaxNumber: | 9725662032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | HADDOCK | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING EMPLOYEE | ||||||||
| AuthorizedOfficialTelephone: | 9725666000 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.