Basic Information
| Provider Information | |||||||||
| NPI: | 1982689113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR INSTITUTE OF THE SOUTH, APMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4176 | ||||||||
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| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703614176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858760300 | ||||||||
| FaxNumber: | 9858720317 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 DUNN ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703604413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858760300 | ||||||||
| FaxNumber: | 9858720317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 12/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | KONUR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9858760300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1795119 | 05 | LA | MEDICAID | CS0290 | 01 | LA | RR MEDICARE | OTHER |