Provider Demographics
NPI:1467640680
Name:CARDIO OF CLARK & CHAMPAIGN
Entity Type:Organization
Organization Name:CARDIO OF CLARK & CHAMPAIGN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KAE
Authorized Official - Last Name:GABBARD
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:937-323-5064
Mailing Address - Street 1:1911 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1227
Mailing Address - Country:US
Mailing Address - Phone:937-323-5064
Mailing Address - Fax:937-323-1407
Practice Address - Street 1:1141 N MONROE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-1619
Practice Address - Country:US
Practice Address - Phone:937-376-8336
Practice Address - Fax:937-376-8352
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARDIOLOGISTS OF CLARK & CHAMPAIGN COUNTIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-12
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0942412Medicaid
OHCM7602OtherRAILROAD MEDICARE
OH0942412Medicaid