Provider Demographics
NPI:1609007087
Name:MOUNT CARMEL HEALTH PROVIDER TWO, LLC
Entity Type:Organization
Organization Name:MOUNT CARMEL HEALTH PROVIDER TWO, LLC
Other - Org Name:MOUNT CARMEL CLINICAL CARDIOVASCULAR SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-546-4621
Mailing Address - Street 1:PO BOX 951144
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0005
Mailing Address - Country:US
Mailing Address - Phone:614-546-4440
Mailing Address - Fax:614-546-4441
Practice Address - Street 1:444 N CLEVELAND AVE
Practice Address - Street 2:SUITE 22
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8387
Practice Address - Country:US
Practice Address - Phone:614-459-7676
Practice Address - Fax:614-459-7681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty