Provider Demographics
NPI:1588852016
Name:CHANGE OF HEART CARDIOLOGY, LLC
Entity Type:Organization
Organization Name:CHANGE OF HEART CARDIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-774-2330
Mailing Address - Street 1:2130 HIGHWAY 35 STE 325C
Mailing Address - Street 2:
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-1010
Mailing Address - Country:US
Mailing Address - Phone:732-774-2330
Mailing Address - Fax:732-774-1882
Practice Address - Street 1:2130 HIGHWAY 35
Practice Address - Street 2:BLDG C STE 321
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-1010
Practice Address - Country:US
Practice Address - Phone:732-974-6700
Practice Address - Fax:732-974-6707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB66061207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ116965Medicare PIN