Provider Demographics
NPI:1770663957
Name:MIDATLANTIC CARDIOTHORACIC & VASCULAR ASSOC
Entity Type:Organization
Organization Name:MIDATLANTIC CARDIOTHORACIC & VASCULAR ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:AZYBUIKE
Authorized Official - Last Name:ANENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-785-9905
Mailing Address - Street 1:501 BATH ROAD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007
Mailing Address - Country:US
Mailing Address - Phone:215-785-9905
Mailing Address - Fax:215-785-6794
Practice Address - Street 1:501 BATH ROAD
Practice Address - Street 2:SUITE 215
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007
Practice Address - Country:US
Practice Address - Phone:215-785-9905
Practice Address - Fax:215-785-6794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066370L208G00000X
NJ25MA06518800208G00000X
208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001820720001Medicaid
2372310OtherAETNA
0824589000OtherIBC
914465OtherHIGHMARK
0152107202OtherAMERICHOICE
0824589000OtherAMERIHEALTH
8438706OtherNJ MEDICAL ASSISTANCE
NJ012207OtherMEDICARE
1125019OtherKEYSTONE MERCY HLTH PLAN
8211867002OtherCIGNA
E82186Medicare UPIN
0152107202OtherAMERICHOICE