Provider Demographics
NPI:1407079304
Name:SOUTH CHARLESTON CARDIODIAGNOSTICS
Entity Type:Organization
Organization Name:SOUTH CHARLESTON CARDIODIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAZIR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:304-766-3688
Mailing Address - Street 1:428 DIVISION ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1469
Mailing Address - Country:US
Mailing Address - Phone:304-766-9617
Mailing Address - Fax:304-766-9626
Practice Address - Street 1:428 DIVISION ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1469
Practice Address - Country:US
Practice Address - Phone:304-766-9617
Practice Address - Fax:304-766-9626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0010978000Medicaid
WV5272533OtherAETNA
WV0010978000Medicaid