Provider Demographics
NPI:1043401870
Name:PROVIDENCE - CARDIOLOGY
Entity Type:Organization
Organization Name:PROVIDENCE - CARDIOLOGY
Other - Org Name:PEDIATRIC SUBSPECIALTY FACULTY, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:FARACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-516-4295
Mailing Address - Street 1:455 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3835
Mailing Address - Country:US
Mailing Address - Phone:714-516-4295
Mailing Address - Fax:
Practice Address - Street 1:1310 W STEWART DR STE 212
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3837
Practice Address - Country:US
Practice Address - Phone:714-516-4295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR009039GMedicaid
CAGR009039DMedicaid
CAGR009039BMedicaid