Provider Demographics
NPI:1902233778
Name:HEART HYPERTENSION CHOLESTEROL & DIABETES CARE LLC
Entity Type:Organization
Organization Name:HEART HYPERTENSION CHOLESTEROL & DIABETES CARE LLC
Other - Org Name:PRIMARY CARE PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-244-9859
Mailing Address - Street 1:15444 DEDEAUX RD STE B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2637
Mailing Address - Country:US
Mailing Address - Phone:228-832-9038
Mailing Address - Fax:228-832-9990
Practice Address - Street 1:15444 DEDEAUX RD STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-832-9038
Practice Address - Fax:228-832-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2019-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01050841Medicaid
MS329259OtherMEDICARE PTAN