Provider Demographics
NPI:1679727531
Name:ADVANCED CARDIOLOGY DIAGNOSTIC CENTERS LLC
Entity type:Organization
Organization Name:ADVANCED CARDIOLOGY DIAGNOSTIC CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-424-1868
Mailing Address - Street 1:6036 N 19TH AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2106
Mailing Address - Country:US
Mailing Address - Phone:602-424-4450
Mailing Address - Fax:602-424-4451
Practice Address - Street 1:2401 W GLENDALE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7677
Practice Address - Country:US
Practice Address - Phone:602-424-1868
Practice Address - Fax:602-424-1874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32892207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ497237Medicaid
Z134568Medicare PIN