Provider Demographics
NPI:1730563909
Name:RADIAL FIRST CARDIOVASCULAR ASSOCIATES, LLC
Entity type:Organization
Organization Name:RADIAL FIRST CARDIOVASCULAR ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LASSETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-318-7757
Mailing Address - Street 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-523-3050
Mailing Address - Fax:208-523-4985
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6371
Practice Address - Country:US
Practice Address - Phone:208-523-3050
Practice Address - Fax:208-523-4985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11673207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM11673Medicaid
1477578300OtherNPI
1477578300OtherNPI