Provider Demographics
NPI:1306361803
Name:STATELINE HEART AND VASCULAR HEALTH, INC
Entity Type:Organization
Organization Name:STATELINE HEART AND VASCULAR HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPAK
Authorized Official - Middle Name:DILIP
Authorized Official - Last Name:BANERJEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-813-6493
Mailing Address - Street 1:20 HUNT COUNTRY FARMS RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-6622
Mailing Address - Country:US
Mailing Address - Phone:757-813-6493
Mailing Address - Fax:
Practice Address - Street 1:312 FAIRY STREET EXT STE 101
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1912
Practice Address - Country:US
Practice Address - Phone:757-813-6493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230554207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty