Provider Demographics
NPI:1093991564
Name:CARDIAC IMAGING CENTER, PLLC.
Entity Type:Organization
Organization Name:CARDIAC IMAGING CENTER, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSHMOUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-419-0395
Mailing Address - Street 1:331 LAIDLEY ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1619
Mailing Address - Country:US
Mailing Address - Phone:304-419-0395
Mailing Address - Fax:
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:SUITE 402
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-419-0395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01010/4730849-01293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0073986000Medicaid