Provider Demographics
NPI:1619948130
Name:HEART CENTER OF NORTHEASTERN ARIZONA, LLC
Entity Type:Organization
Organization Name:HEART CENTER OF NORTHEASTERN ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NPI
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-532-1970
Mailing Address - Street 1:PO BOX 3179
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85902-3179
Mailing Address - Country:US
Mailing Address - Phone:928-532-0600
Mailing Address - Fax:928-532-0550
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:CATH LAB
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7881
Practice Address - Country:US
Practice Address - Phone:928-532-1970
Practice Address - Fax:928-532-1969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3497207RC0000X, 207RI0011X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ848707Medicaid
AZZ73532Medicare PIN