Provider Demographics
NPI:1679574156
Name:WEST SIDE CARDIOTHORACIC SURGEONS, INC.
Entity Type:Organization
Organization Name:WEST SIDE CARDIOTHORACIC SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:M.
Authorized Official - Middle Name:HANI
Authorized Official - Last Name:KHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-521-3384
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0567
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:15644 MADISON AVE
Practice Address - Street 2:SUITE #202
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5622
Practice Address - Country:US
Practice Address - Phone:216-521-3384
Practice Address - Fax:216-521-3385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherEIN
OH=========OtherEIN