Provider Demographics
NPI:1801194352
Name:LAKESIDE HEART AND VASCULAR CENTER PLLC
Entity Type:Organization
Organization Name:LAKESIDE HEART AND VASCULAR CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:ATASSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-453-2727
Mailing Address - Street 1:PO BOX 3539
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-3539
Mailing Address - Country:US
Mailing Address - Phone:928-453-2727
Mailing Address - Fax:928-453-2828
Practice Address - Street 1:1741 MESQUITE AVE
Practice Address - Street 2:SUITE A100
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5695
Practice Address - Country:US
Practice Address - Phone:928-453-2727
Practice Address - Fax:928-453-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44211207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP-1663566-8OtherARIZONA CORPORATION COMMISSION FILING NUMBER
AZ604490Medicaid
AZ604490Medicaid