Provider Demographics
NPI:1922299759
Name:CANTON CARDIOLOGY CLINIC
Entity Type:Organization
Organization Name:CANTON CARDIOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-936-3102
Mailing Address - Street 1:1421 E PEACE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-4938
Mailing Address - Country:US
Mailing Address - Phone:601-855-0231
Mailing Address - Fax:
Practice Address - Street 1:1421 E PEACE ST
Practice Address - Street 2:SUITE D
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4938
Practice Address - Country:US
Practice Address - Phone:601-855-0231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03614Medicare PIN