Provider Demographics
NPI:1760672521
Name:MT SHASTA CARDIOLOGY, INC
Entity Type:Organization
Organization Name:MT SHASTA CARDIOLOGY, INC
Other - Org Name:MT SHASTA CARDIOLOGY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CARDIOLIGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-926-4401
Mailing Address - Street 1:PO BOX 1253
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-1253
Mailing Address - Country:US
Mailing Address - Phone:530-926-4401
Mailing Address - Fax:530-926-3791
Practice Address - Street 1:110 W CASTLE ST STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2165
Practice Address - Country:US
Practice Address - Phone:530-926-4067
Practice Address - Fax:530-926-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADG9564OtherRAILROAD MEDICARE
CA00A304480Medicaid
CADG9564OtherRAILROAD MEDICARE