Provider Demographics
NPI:1922089416
Name:HEART INSTITUTE OF NORTHERN ARIZONA LLC
Entity Type:Organization
Organization Name:HEART INSTITUTE OF NORTHERN ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-815-7804
Mailing Address - Street 1:10720 SIKES PL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8141
Mailing Address - Country:US
Mailing Address - Phone:704-815-7789
Mailing Address - Fax:888-401-6931
Practice Address - Street 1:1753 AIRWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3720
Practice Address - Country:US
Practice Address - Phone:928-692-6200
Practice Address - Fax:928-692-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ930348Medicaid
AZ470000205OtherRAILROAD MEDICARE
AZ197211Medicaid
AZ470000205OtherRAILROAD MEDICARE