Provider Demographics
NPI:1154554616
Name:CARDIOLOGY ASSOCIATES OF WYTHEVILLE
Entity type:Organization
Organization Name:CARDIOLOGY ASSOCIATES OF WYTHEVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER/COL (R)
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACC, FCCP
Authorized Official - Phone:276-228-5506
Mailing Address - Street 1:175 W MONROE ST
Mailing Address - Street 2:BOX 266
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2341
Mailing Address - Country:US
Mailing Address - Phone:276-228-5506
Mailing Address - Fax:276-228-9600
Practice Address - Street 1:360 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1185
Practice Address - Country:US
Practice Address - Phone:276-228-5506
Practice Address - Fax:276-228-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246201207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154554616Medicaid
VAD19254Medicare UPIN
VAC10865Medicare PIN