Provider Demographics
NPI:1366690257
Name:JETTY HEART CLINIC OF THE INDIANA HEART HOSPITAL LLC
Entity Type:Organization
Organization Name:JETTY HEART CLINIC OF THE INDIANA HEART HOSPITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALASTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-621-8050
Mailing Address - Street 1:1210 MEDICAL ARTS BLVD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3439
Mailing Address - Country:US
Mailing Address - Phone:765-298-4422
Mailing Address - Fax:765-298-4926
Practice Address - Street 1:1210 MEDICAL ARTS BLVD
Practice Address - Street 2:SUITE 217
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3439
Practice Address - Country:US
Practice Address - Phone:765-298-4422
Practice Address - Fax:765-298-4926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040154A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000586511OtherANTHEM
IN258000Medicare PIN