Provider Demographics
NPI:1699718312
Name:ROSEVILLE CARDIOLOGY MEDICAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:ROSEVILLE CARDIOLOGY MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:WAMPOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-782-2146
Mailing Address - Street 1:2 MEDICAL PLAZA DR
Mailing Address - Street 2:#175
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3049
Mailing Address - Country:US
Mailing Address - Phone:916-782-2146
Mailing Address - Fax:916-782-4299
Practice Address - Street 1:2 MEDICAL PLAZA DR
Practice Address - Street 2:#175
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3049
Practice Address - Country:US
Practice Address - Phone:916-782-2146
Practice Address - Fax:916-782-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41602207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ06970ZOtherBLUE SHIELD
CAGR0094900Medicaid
ZZZ26246ZMedicare PIN
DA2016Medicare PIN