Provider Demographics
NPI:1205076387
Name:RUSSELLVILLE CARDIOLOGY CONSULTANTS, PA
Entity type:Organization
Organization Name:RUSSELLVILLE CARDIOLOGY CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAI
Authorized Official - Middle Name:YUAN
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-968-4311
Mailing Address - Street 1:106 S INGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3353
Mailing Address - Country:US
Mailing Address - Phone:479-968-4311
Mailing Address - Fax:479-968-4399
Practice Address - Street 1:106 S INGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3353
Practice Address - Country:US
Practice Address - Phone:479-968-4311
Practice Address - Fax:479-968-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5291207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARI24377Medicare UPIN