Provider Demographics
NPI:1144231465
Name:COMMONWEALTH CARDIOLOGISTS PSC
Entity type:Organization
Organization Name:COMMONWEALTH CARDIOLOGISTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-584-2029
Mailing Address - Street 1:210 E GRAY ST
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3900
Mailing Address - Country:US
Mailing Address - Phone:502-584-2029
Mailing Address - Fax:502-584-0873
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 1002
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-584-2029
Practice Address - Fax:502-584-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100019450Medicaid
KY2432852000OtherKY PASSPORT ADVANTAGE
KY65919896Medicaid
KY1050407OtherKY GROUP PASSPORT
IN100019450Medicaid
KY1050407OtherKY GROUP PASSPORT
KY2432852000OtherKY PASSPORT ADVANTAGE