Provider Demographics
NPI:1679502470
Name:HAVASU CARDIAC SURGERY PC
Entity Type:Organization
Organization Name:HAVASU CARDIAC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:R
Authorized Official - Last Name:TIBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-253-9168
Mailing Address - Street 1:3131 E CLARENDON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7069
Mailing Address - Country:US
Mailing Address - Phone:602-253-9168
Mailing Address - Fax:602-251-3126
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:ATTN: HAVASU CARDIAC SURGERY
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-854-0090
Practice Address - Fax:928-453-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ117724Medicaid
AZ117724Medicaid