Provider Demographics
NPI:1568643229
Name:OLD PUEBLO CARDIOLOGY PC
Entity Type:Organization
Organization Name:OLD PUEBLO CARDIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-323-7277
Mailing Address - Street 1:PO BOX 64086
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85728-4086
Mailing Address - Country:US
Mailing Address - Phone:520-323-7277
Mailing Address - Fax:520-881-1968
Practice Address - Street 1:3955 E FORT LOWELL RD
Practice Address - Street 2:SUITE 113
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1041
Practice Address - Country:US
Practice Address - Phone:520-323-7277
Practice Address - Fax:520-881-1968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ119329OtherPTAN