Provider Demographics
NPI:1376791806
Name:CARDIOVASCULAR INSTITUE OF SELMA, LLC
Entity Type:Organization
Organization Name:CARDIOVASCULAR INSTITUE OF SELMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMJAD
Authorized Official - Middle Name:I
Authorized Official - Last Name:BUTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-875-3588
Mailing Address - Street 1:1023 MEDICAL CENTER PKWY
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6780
Mailing Address - Country:US
Mailing Address - Phone:334-875-3588
Mailing Address - Fax:334-875-3589
Practice Address - Street 1:1023 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 311
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6780
Practice Address - Country:US
Practice Address - Phone:334-875-3588
Practice Address - Fax:334-875-3589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G18370Medicare UPIN