Provider Demographics
NPI:1194838383
Name:DOWNRIVER HEART AND VASCULAR SPECIALISTS PC
Entity Type:Organization
Organization Name:DOWNRIVER HEART AND VASCULAR SPECIALISTS PC
Other - Org Name:K A GOWDA MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOEDERLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-282-4800
Mailing Address - Street 1:15150 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1302
Mailing Address - Country:US
Mailing Address - Phone:734-282-4800
Mailing Address - Fax:734-282-5039
Practice Address - Street 1:15150 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1302
Practice Address - Country:US
Practice Address - Phone:734-282-4800
Practice Address - Fax:734-282-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRR MEDICAREOtherDF1147
MIMEDICAIDMedicaid
MI0H23923OtherBLUE CROSS GROUP NUMBER