Provider Demographics
NPI:1821369307
Name:MIDWEST CARDIOVASCULAR CONSULTANTS LLC
Entity Type:Organization
Organization Name:MIDWEST CARDIOVASCULAR CONSULTANTS LLC
Other - Org Name:CARDIOCARE CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7334
Mailing Address - Street 1:1250 RALSTON AVE
Mailing Address - Street 2:SUITE 203A
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-5311
Mailing Address - Country:US
Mailing Address - Phone:419-783-6895
Mailing Address - Fax:419-782-4459
Practice Address - Street 1:1250 RALSTON AVE
Practice Address - Street 2:SUITE 203A
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-5311
Practice Address - Country:US
Practice Address - Phone:419-783-6895
Practice Address - Fax:419-782-4459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty