Provider Demographics
NPI:1871531897
Name:CLARKSBURG CARDIOLOGY CONSULTANTS
Entity type:Organization
Organization Name:CLARKSBURG CARDIOLOGY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:S.M.
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-933-3830
Mailing Address - Street 1:527 MEDICAL PARK DRIVE
Mailing Address - Street 2:STE 306
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9008
Mailing Address - Country:US
Mailing Address - Phone:304-933-3830
Mailing Address - Fax:304-933-3837
Practice Address - Street 1:527 MEDICAL PARK DRIVE
Practice Address - Street 2:STE 306
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9008
Practice Address - Country:US
Practice Address - Phone:304-933-3830
Practice Address - Fax:304-933-3837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV044134207RC0000X
207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011726000Medicaid
WV1327565OtherUWMA GROUP
WV1327565OtherUMW GROUP
WV000465033OtherBCBS GROUP
WV000465033Medicaid
WV9919981Medicare UPIN