Provider Demographics
NPI:1215980479
Name:CARDIOVASCULAR GROUP, PC
Entity type:Organization
Organization Name:CARDIOVASCULAR GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LILES
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS, CPMSM
Authorized Official - Phone:678-252-3735
Mailing Address - Street 1:755 WALTHER RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8725
Mailing Address - Country:US
Mailing Address - Phone:678-252-3735
Mailing Address - Fax:678-252-3722
Practice Address - Street 1:755 WALTHER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8725
Practice Address - Country:US
Practice Address - Phone:678-252-3735
Practice Address - Fax:678-252-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG1307Medicare ID - Type Unspecified