Provider Demographics
NPI:1083684948
Name:CARDIOVASCULAR ASSOCIATES OF NORTHEASTERN INDIANA LLC
Entity Type:Organization
Organization Name:CARDIOVASCULAR ASSOCIATES OF NORTHEASTERN INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CSICSKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-6098
Mailing Address - Street 1:7900 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4128
Mailing Address - Country:US
Mailing Address - Phone:260-436-6098
Mailing Address - Fax:260-436-3173
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-436-6098
Practice Address - Fax:260-436-3173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200049160AMedicaid
INCA5617OtherTAVELERS MEDICARE
IN200049160AMedicaid
IN667590Medicare PIN