Provider Demographics
NPI:1831171370
Name:CARDIO VASCULAR THORACIC SURGERY LLC
Entity type:Organization
Organization Name:CARDIO VASCULAR THORACIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOS-CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-886-4383
Mailing Address - Street 1:PO BOX 1823
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-7823
Mailing Address - Country:US
Mailing Address - Phone:812-886-4383
Mailing Address - Fax:812-886-4385
Practice Address - Street 1:520 S 7TH ST
Practice Address - Street 2:GOOD SAMARITIAN HOSPITAL
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1038
Practice Address - Country:US
Practice Address - Phone:812-885-3243
Practice Address - Fax:812-885-3915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010456972086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND08549Medicare UPIN
IN197370AMedicare ID - Type UnspecifiedMEDICARE NUMBER