Provider Demographics
NPI:1770501256
Name:CARDIAC CARE CONSULTANTS, PC
Entity Type:Organization
Organization Name:CARDIAC CARE CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:CANELAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-836-9677
Mailing Address - Street 1:1730 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3915
Mailing Address - Country:US
Mailing Address - Phone:219-836-9677
Mailing Address - Fax:219-836-0688
Practice Address - Street 1:1730 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3915
Practice Address - Country:US
Practice Address - Phone:219-836-9677
Practice Address - Fax:219-836-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040667207RI0011X
IN01042616207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200465870Medicaid
IN200465870Medicaid