Provider Demographics
NPI:1467453019
Name:ADVANCED CARDIAC SPECIALISTS, CHARTERED
Entity Type:Organization
Organization Name:ADVANCED CARDIAC SPECIALISTS, CHARTERED
Other - Org Name:ADVANCED CARDIAC SPECIALISTS OUTPATIENT TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:480-545-1808
Mailing Address - Street 1:PO BOX 63423
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-3423
Mailing Address - Country:US
Mailing Address - Phone:480-892-2800
Mailing Address - Fax:480-982-1400
Practice Address - Street 1:515 N MESA DR
Practice Address - Street 2:STE. 100
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5914
Practice Address - Country:US
Practice Address - Phone:480-461-4454
Practice Address - Fax:480-982-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3437261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ159138-01Medicaid
AZZ26859Medicare PIN
AZ470000143Medicare PIN