Provider Demographics
NPI:1215366893
Name:GREATER NILES CARDIOLOGY PC
Entity Type:Organization
Organization Name:GREATER NILES CARDIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORTUNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-687-9575
Mailing Address - Street 1:24 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE F1
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2263
Mailing Address - Country:US
Mailing Address - Phone:269-687-9575
Mailing Address - Fax:269-687-9596
Practice Address - Street 1:24 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE F1
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-687-9575
Practice Address - Fax:269-687-9596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079120207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty