Provider Demographics
NPI:1639213978
Name:MIDWEST CARDIOVASCULAR CONSTULTANTS, LLC
Entity Type:Organization
Organization Name:MIDWEST CARDIOVASCULAR CONSTULTANTS, LLC
Other - Org Name:CARDIOCARE CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7221
Mailing Address - Street 1:1601 BRIGHAM DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7114
Mailing Address - Country:US
Mailing Address - Phone:419-872-7703
Mailing Address - Fax:419-872-1704
Practice Address - Street 1:1601 BRIGHAM DR
Practice Address - Street 2:SUITE 120
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7114
Practice Address - Country:US
Practice Address - Phone:419-872-7703
Practice Address - Fax:419-872-1704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7663459OtherAETNA
OHDA2406OtherRRMC
OH2421605Medicaid
OH2421605Medicaid
OHDA2406OtherRRMC