Provider Demographics
NPI:1720405178
Name:PHILADELPHIA PREMIER CARDIOVASCULAR CONSULTANTS LLC
Entity Type:Organization
Organization Name:PHILADELPHIA PREMIER CARDIOVASCULAR CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRIELUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-383-5900
Mailing Address - Street 1:628 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1617
Mailing Address - Country:US
Mailing Address - Phone:215-383-5900
Mailing Address - Fax:855-777-8654
Practice Address - Street 1:7452 OGONTZ AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1324
Practice Address - Country:US
Practice Address - Phone:215-383-5900
Practice Address - Fax:855-777-8654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205831716Medicaid
NY02840224Medicaid