Provider Demographics
NPI:1477884740
Name:STAR STATE HEART PLLC
Entity Type:Organization
Organization Name:STAR STATE HEART PLLC
Other - Org Name:STAR STATE HEART & VASCULAR PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEMAIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-263-0123
Mailing Address - Street 1:PO BOX POX # 731393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1393
Mailing Address - Country:US
Mailing Address - Phone:512-263-0123
Mailing Address - Fax:512-367-5841
Practice Address - Street 1:200 MEDICAL PKWY
Practice Address - Street 2:SUITE 270
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-1782
Practice Address - Country:US
Practice Address - Phone:512-263-0123
Practice Address - Fax:512-367-5841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6655207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134703111OtherMEDICAID
TX211911702OtherMEDICAID
TXTXB144746OtherMEDICARE
TXTXB144747OtherMEDICARE
TX8F24108OtherMEDICARE
TX0A6024Medicare PIN