Provider Demographics
NPI:1053512632
Name:ARIZONA HEART INSTITUTE LAKE HAVASU
Entity Type:Organization
Organization Name:ARIZONA HEART INSTITUTE LAKE HAVASU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-266-2200
Mailing Address - Street 1:PO BOX 61773
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1773
Mailing Address - Country:US
Mailing Address - Phone:602-682-6727
Mailing Address - Fax:602-240-6177
Practice Address - Street 1:1845 MCCULLOCH BLVD N
Practice Address - Street 2:SUITE A6
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6759
Practice Address - Country:US
Practice Address - Phone:520-505-4442
Practice Address - Fax:602-240-6177
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARIZONA HEART INSTITUTE LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTAX ID#
AZZWDBMRMedicare PIN