Provider Demographics
NPI:1801970439
Name:CHRISTIAN CARDIOLOGY INTERNAL MEDICINE
Entity type:Organization
Organization Name:CHRISTIAN CARDIOLOGY INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLATZ
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:606-598-5807
Mailing Address - Street 1:113 MAIN ST
Mailing Address - Street 2:PO BOX 159
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-1258
Mailing Address - Country:US
Mailing Address - Phone:606-598-5807
Mailing Address - Fax:606-599-8898
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-1258
Practice Address - Country:US
Practice Address - Phone:606-598-5807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65930133Medicaid
KY65930133Medicaid