Basic Information
| Provider Information | |||||||||
| NPI: | 1699761197 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | S J H CARDIAC CATHETERIZATION ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4820 W TAFT RD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130882800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154486215 | ||||||||
| FaxNumber: | 3152344416 | ||||||||
| Practice Location | |||||||||
| Address1: | 4820 W TAFT RD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130882800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154486215 | ||||||||
| FaxNumber: | 3152344416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | AL-MUDAMGHA | ||||||||
| AuthorizedOfficialFirstName: | ALI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3152340906 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 02130050 | 05 | NY | MEDICAID |