Provider Demographics
NPI:1871512160
Name:CARDIOVASCULAR SPECIALISTS PSC
Entity Type:Organization
Organization Name:CARDIOVASCULAR SPECIALISTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTODULOS
Authorized Official - Middle Name:S
Authorized Official - Last Name:STAVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-589-7907
Mailing Address - Street 1:100 MALLARD CREEK RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-5138
Mailing Address - Country:US
Mailing Address - Phone:502-589-7907
Mailing Address - Fax:502-589-1319
Practice Address - Street 1:100 MALLARD CREEK RD
Practice Address - Street 2:SUITE 150
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5138
Practice Address - Country:US
Practice Address - Phone:502-589-7907
Practice Address - Fax:502-589-1319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCI7476OtherRAILROAD MEDICARE
KY1093228OtherPASSPORT HEALTH PLAN
IN200208100Medicaid
KY65931560Medicaid
KYCI6702OtherRAILROAD MEDICARE
IN200208100Medicaid
IN084820Medicare PIN
KY00181Medicare PIN
KY2435976000OtherPASSPORT ADVANTAGE PLAN
KYCI6702OtherRAILROAD MEDICARE
KY=========0A00OtherANTHEM SR. ADVANTAGE
IN084820Medicare ID - Type Unspecified
KY8749Medicare ID - Type Unspecified
IN200208100AMedicaid
INCI7476OtherRAILROAD MEDICARE
IN200208100DMedicaid
KY8753Medicare PIN
IN200208100FMedicaid
KY8751Medicare PIN
IN200208100GMedicaid