Provider Demographics
NPI:1356523773
Name:ONSITE CARDIOVASCULAR IMAG
Entity type:Organization
Organization Name:ONSITE CARDIOVASCULAR IMAG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:FREDERIC
Authorized Official - Last Name:HOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:RDCS RVS
Authorized Official - Phone:480-987-8762
Mailing Address - Street 1:22830 S 197TH WAY
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-8309
Mailing Address - Country:US
Mailing Address - Phone:480-987-8762
Mailing Address - Fax:480-987-8765
Practice Address - Street 1:22830 S 197TH WAY
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-8309
Practice Address - Country:US
Practice Address - Phone:480-987-8762
Practice Address - Fax:480-987-8765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ101209Medicare PIN