Provider Demographics
NPI:1396897286
Name:DIAGNOSTIC AND INTERVENTIONAL CARDIOLOGY ASSOCIATES, P.A
Entity type:Organization
Organization Name:DIAGNOSTIC AND INTERVENTIONAL CARDIOLOGY ASSOCIATES, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVYN
Authorized Official - Middle Name:VANROY
Authorized Official - Last Name:MAHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACC
Authorized Official - Phone:803-252-1076
Mailing Address - Street 1:2753 LAUREL ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2021
Mailing Address - Country:US
Mailing Address - Phone:803-252-1076
Mailing Address - Fax:803-779-6339
Practice Address - Street 1:2753 LAUREL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2021
Practice Address - Country:US
Practice Address - Phone:803-252-1076
Practice Address - Fax:803-779-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1217Medicaid
SC126205Medicaid
SCGP2525Medicaid
SC126205Medicaid
SCGP1217Medicaid
SCGP2525Medicaid