Provider Demographics
NPI:1285805879
Name:CARDIOVASCULAR DISEASES OF NILES, P.C.
Entity type:Organization
Organization Name:CARDIOVASCULAR DISEASES OF NILES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUNDATHAJE
Authorized Official - Middle Name:ISHWARA
Authorized Official - Last Name:BHAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-683-1120
Mailing Address - Street 1:24 N SAINT JOSEPH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2263
Mailing Address - Country:US
Mailing Address - Phone:269-683-1120
Mailing Address - Fax:269-683-4325
Practice Address - Street 1:24 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-683-1120
Practice Address - Fax:269-683-4325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI42240207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0601110821OtherBCBS MI
MI101365131Medicaid
MIOP55400Medicare PIN
D83136Medicare UPIN
IN183190Medicare PIN