Provider Demographics
NPI:1689071391
Name:LIFETIME CARDIOVASCULAR, PLC
Entity Type:Organization
Organization Name:LIFETIME CARDIOVASCULAR, PLC
Other - Org Name:LIFETIME HEART AND VASCULAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GAUTAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KEDIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-699-5536
Mailing Address - Street 1:2487 S GILBERT RD
Mailing Address - Street 2:STE 106-486
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8899
Mailing Address - Country:US
Mailing Address - Phone:480-699-5536
Mailing Address - Fax:480-699-9283
Practice Address - Street 1:287 E HUNT HWY
Practice Address - Street 2:STE 105
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5095
Practice Address - Country:US
Practice Address - Phone:480-699-5536
Practice Address - Fax:480-699-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872220Medicaid
AZ872220Medicaid