Provider Demographics
NPI:1609048404
Name:PACIFIC HEART ASSOCIATES PC
Entity Type:Organization
Organization Name:PACIFIC HEART ASSOCIATES PC
Other - Org Name:CARDIAC CONSULTANTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAZRINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-790-1234
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:SUITE 660
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3057
Mailing Address - Country:US
Mailing Address - Phone:503-790-1234
Mailing Address - Fax:503-790-0234
Practice Address - Street 1:1730 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3137
Practice Address - Country:US
Practice Address - Phone:888-464-4267
Practice Address - Fax:503-790-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287001Medicaid
ORR0000WCHVVMedicare PIN