Provider Demographics
NPI:1407875636
Name:INDIANA CARDIAC & VASCULAR CONSULTANTS
Entity Type:Organization
Organization Name:INDIANA CARDIAC & VASCULAR CONSULTANTS
Other - Org Name:CENTRAL INDIANA PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HABIB
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KOMARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-988-8116
Mailing Address - Street 1:50 WILLOW ST STE C
Mailing Address - Street 2:PO BOX 215
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-7013
Mailing Address - Country:US
Mailing Address - Phone:812-988-8116
Mailing Address - Fax:812-988-8132
Practice Address - Street 1:50 WILLOW ST
Practice Address - Street 2:SUITE C
Practice Address - City:NASHVILLE
Practice Address - State:IN
Practice Address - Zip Code:47448-7031
Practice Address - Country:US
Practice Address - Phone:812-988-8116
Practice Address - Fax:812-988-8132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040158A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCN5946OtherRR MEDICARE
IN219070Medicare PIN