Provider Demographics
NPI:1578128591
Name:INTERVENTIONAL CARDIOLOGY OF TULSA, LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL CARDIOLOGY OF TULSA, LLC
Other - Org Name:TULSA CARDIOVASCULAR CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:COMSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-943-5303
Mailing Address - Street 1:P.O. BOX 25011
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2001
Mailing Address - Country:US
Mailing Address - Phone:918-943-5303
Mailing Address - Fax:918-943-5302
Practice Address - Street 1:11912 S NORWOOD AVE STE 110
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-5509
Practice Address - Country:US
Practice Address - Phone:918-943-5303
Practice Address - Fax:918-943-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty