Provider Demographics
NPI:1588600688
Name:ACADEMIC HEART & VASCULAR PLLC
Entity Type:Organization
Organization Name:ACADEMIC HEART & VASCULAR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:O
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:248-898-5593
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:BEAUMONT HEART CENTER CLINIC
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:248-898-4163
Mailing Address - Fax:248-898-5596
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:BEAUMONT HEART CENTER CLINIC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-4163
Practice Address - Fax:248-898-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N39200Medicare ID - Type Unspecified