Provider Demographics
NPI:1649555467
Name:CARDIAC RENAL & VASCULAR ASSOCIATES PC
Entity type:Organization
Organization Name:CARDIAC RENAL & VASCULAR ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUROTIMI
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BADERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-750-5736
Mailing Address - Street 1:5240 ROBINSON ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-4276
Mailing Address - Country:US
Mailing Address - Phone:601-398-0904
Mailing Address - Fax:601-398-2149
Practice Address - Street 1:5240 ROBINSON ROAD EXT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4276
Practice Address - Country:US
Practice Address - Phone:601-398-0904
Practice Address - Fax:601-398-2149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21527207RN0300X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty