Provider Demographics
NPI:1164452900
Name:CARDIOLOGISTS OF CLARK & CHAMPAIGN COUNTIES
Entity Type:Organization
Organization Name:CARDIOLOGISTS OF CLARK & CHAMPAIGN COUNTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KAE
Authorized Official - Last Name:GABBARD
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:937-523-9555
Mailing Address - Street 1:100 W. MCCREIGHT AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504
Mailing Address - Country:US
Mailing Address - Phone:937-323-1404
Mailing Address - Fax:937-323-1407
Practice Address - Street 1:100 W. MCCREIGHT AVE
Practice Address - Street 2:STE 150
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504
Practice Address - Country:US
Practice Address - Phone:937-323-1404
Practice Address - Fax:937-323-1407
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARDIOLOGIST OF CLARK & CHAMPAIGN COUNTIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RC0000X207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0942412Medicaid
OHCM7602OtherRAILROAD MEDICARE
OH0942412Medicaid