Provider Demographics
NPI:1275960908
Name:GREAT RIVER CARDIOLOGY, INC
Entity Type:Organization
Organization Name:GREAT RIVER CARDIOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHOKA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAUTIYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-333-7315
Mailing Address - Street 1:24700 CENTER RIDGE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5669
Mailing Address - Country:US
Mailing Address - Phone:440-333-7315
Mailing Address - Fax:440-808-8303
Practice Address - Street 1:24700 CENTER RIDGE RD STE 220
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5669
Practice Address - Country:US
Practice Address - Phone:440-333-7315
Practice Address - Fax:440-808-8303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086804207RC0000X, 207RC0001X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0097959Medicaid
OH2614371Medicaid