Provider Demographics
NPI:1952640781
Name:STATE OF THE HEART CARDIOLOGY
Entity Type:Organization
Organization Name:STATE OF THE HEART CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-310-3070
Mailing Address - Street 1:3801 WILLIAM D TATE AVE
Mailing Address - Street 2:SUITE 850
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8755
Mailing Address - Country:US
Mailing Address - Phone:817-310-3070
Mailing Address - Fax:817-310-0023
Practice Address - Street 1:3801 WILLIAM D TATE AVE
Practice Address - Street 2:SUITE 850
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8755
Practice Address - Country:US
Practice Address - Phone:817-310-3070
Practice Address - Fax:817-310-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08026261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA08026OtherTEXAS MEDICAL BOARD