Provider Demographics
NPI:1891013199
Name:PACIFIC RIM CARDIOVASCULAR INC
Entity Type:Organization
Organization Name:PACIFIC RIM CARDIOVASCULAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:WATERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-268-5789
Mailing Address - Street 1:PO BOX 923
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-0923
Mailing Address - Country:US
Mailing Address - Phone:808-268-5789
Mailing Address - Fax:
Practice Address - Street 1:385 HUKILIKE ST.
Practice Address - Street 2:SUITE 210
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732
Practice Address - Country:US
Practice Address - Phone:808-871-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI150552086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ASG99474Medicare UPIN
HIG99474Medicare UPIN