Provider Demographics
NPI:1396719480
Name:INTERVENTIONAL CARDIOLOGY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:INTERVENTIONAL CARDIOLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS & DEVLOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:LACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-702-8800
Mailing Address - Street 1:7301 MEDICAL CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1935
Mailing Address - Country:US
Mailing Address - Phone:818-702-8800
Mailing Address - Fax:818-702-0080
Practice Address - Street 1:7301 MEDICAL CENTER DR STE 201
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1935
Practice Address - Country:US
Practice Address - Phone:818-702-8800
Practice Address - Fax:818-702-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RI0011X, 207UN0902X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW10342Medicare ID - Type UnspecifiedMEDICARE PROVIDER