Provider Demographics
NPI:1891745709
Name:CARDIOVASCULAR INSTITUTE
Entity Type:Organization
Organization Name:CARDIOVASCULAR INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KRZYSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-534-8723
Mailing Address - Street 1:1175 COOK RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8201
Mailing Address - Country:US
Mailing Address - Phone:803-534-8723
Mailing Address - Fax:803-536-0030
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:SUITE 225
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-534-8723
Practice Address - Fax:803-536-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12677207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA4003Medicaid
SC1857Medicare ID - Type Unspecified
SCPA4003Medicaid