Provider Demographics
NPI:1699750695
Name:CARDIAC DIAGNOSTIC CENTER LLC
Entity type:Organization
Organization Name:CARDIAC DIAGNOSTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAT
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-543-5270
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:SUITE 281B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-543-5270
Mailing Address - Fax:314-543-5289
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 281B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-543-5270
Practice Address - Fax:314-543-5289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4560207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA11496OtherMERCY
MO8285720OtherCIGNA
MO511284OtherHEALTHLINK
MO27454OtherBLUE CHOICE
MO157621OtherBLUE CROSS/ BLUE SHIELD
MOCJ7575OtherRAILROAD MEDICARE
MOCJ7575OtherRAILROAD MEDICARE
MOA11496OtherMERCY