Provider Demographics
NPI:1427035617
Name:CARDIOVASCULAR CONSULTANTS MEDICAL GROUP
Entity Type:Organization
Organization Name:CARDIOVASCULAR CONSULTANTS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LITKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-782-5041
Mailing Address - Street 1:16542 VENTURA BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4562
Mailing Address - Country:US
Mailing Address - Phone:818-782-5041
Mailing Address - Fax:818-205-9091
Practice Address - Street 1:16542 VENTURA BLVD STE 402
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4562
Practice Address - Country:US
Practice Address - Phone:818-782-5041
Practice Address - Fax:818-205-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP7299174400000X
CA207RC0000X, 207RC0001X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0026711Medicaid
CAGR0026710Medicaid
CAGR0026712Medicaid
CAW119CMedicare PIN
CAW119Medicare PIN
CAGR0026711Medicaid
CAW119AMedicare PIN
CAGR0026712Medicaid