Provider Demographics
NPI:1659555712
Name:RISING PHOENIX HEART INSTITUTE, SC
Entity Type:Organization
Organization Name:RISING PHOENIX HEART INSTITUTE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NADIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSSAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-541-7158
Mailing Address - Street 1:2323 S 109TH ST
Mailing Address - Street 2:SUITE 195
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1909
Mailing Address - Country:US
Mailing Address - Phone:414-541-7158
Mailing Address - Fax:414-541-7514
Practice Address - Street 1:2323 S 109TH ST
Practice Address - Street 2:SUITE 195
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1909
Practice Address - Country:US
Practice Address - Phone:414-541-7158
Practice Address - Fax:414-541-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34544174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI110200829OtherMEDICARE RAILROAD
WI32454600Medicaid
WI110200829OtherMEDICARE RAILROAD