Basic Information
Provider Information | |||||||||
NPI: | 1467788463 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARDIOLOGY ASSOCIATES, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4300 W MAIN ST | ||||||||
Address2: | SUITE 102 | ||||||||
City: | DOTHAN | ||||||||
State: | AL | ||||||||
PostalCode: | 363051054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3347939564 | ||||||||
FaxNumber: | 3346718907 | ||||||||
Practice Location | |||||||||
Address1: | 1118 ROSS CLARK CIR | ||||||||
Address2: | SUITE 501 | ||||||||
City: | DOTHAN | ||||||||
State: | AL | ||||||||
PostalCode: | 363013041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3347939564 | ||||||||
FaxNumber: | 3346718907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2009 | ||||||||
LastUpdateDate: | 10/26/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REEVES | ||||||||
AuthorizedOfficialFirstName: | MELISSA | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3347939564 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | CE0117 | 01 | AL | RAILROAD MEDICARE | OTHER | 528400090 | 05 | AL |   | MEDICAID | 054641100 | 05 | FL |   | MEDICAID |