Provider Demographics
NPI:1205476223
Name:MID-AMERICA HEART AND VASCULAR, LLC
Entity type:Organization
Organization Name:MID-AMERICA HEART AND VASCULAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AZAMUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-931-7101
Mailing Address - Street 1:1439 US HIGHWAY 61 STE A
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4154
Mailing Address - Country:US
Mailing Address - Phone:636-931-7101
Mailing Address - Fax:
Practice Address - Street 1:1439 US HIGHWAY 61 STE A
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4154
Practice Address - Country:US
Practice Address - Phone:636-931-7101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-07
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty