Lakeside Heart and Vascular Center PLLC
Organization Active NPI Interventional Cardiology Physician · Lake Havasu City, AZ
NPI 1801194352 · NPPES record last updated Jul 20, 2011
Key facts
- NPI
- 1801194352
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Interventional Cardiology Physician 207RI0011X
- License
- 44211 (AZ)
- Legal business name
- LAKESIDE HEART AND VASCULAR CENTER PLLC
- Practice address
- 1741 Mesquite Ave
Suite A100
Lake Havasu City, AZ 86403-5695 - Phone
- (928) 453-2727
- Fax
- (928) 453-2828
- NPI assigned
- Mar 8, 2011
- Organization subpart
- No
Authorized official
- Name
- Fadi Atassi, M.D.
- Title
- Owner/Member
- Phone
- (928) 453-2727
Practitioners 44
-
Kalkidan Abebe, MD
-
Jenniffer Blair, FNP-C
-
Rafael Francisco Chupeco Go, MD, MBA, MS
-
George P Jolly, M.D.
-
James Kneller, MD
-
Brittney Mahnke, ACNP-AG
-
Paul Andrew Mahnke, ACNPC-AG
-
Traci Moore, APRN, FNP-C
-
Anthony C Pozun, D.O.
-
Edward J Quinn, MD
-
Shayef A Gabasha, MD
-
George M Garcia, MD
-
Fadi Atassi, MD
-
Madeeha Banu, MD
-
Amanda Siegel, PA-C
-
Oday Al Rabadi, M.D.
-
Patricia Gwen Folden, FNP
-
Ruth Anne Franco, NURSE PRACTITIONER
-
Aditya R Goud, M.D.
-
Gene Kalin, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in AZ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110713000658 | AZ | Part B Supplier - Clinic/Group Practice | 4587832779 |
Receives reassigned benefits from 39 practitioners Practice locations: Kingman, AZ; Bullhead City, AZ; Prescott Valley, AZ; Parker, AZ; Lake Havasu City, AZ |
| O20241007002714 | AZ | Part B Supplier - Intensive Cardiac Rehabilitation | 4587832779 |
Receives reassigned benefits from 1 practitioner Practice locations: Lake Havasu City, AZ |
National Provider Directory
Locations
2020 Silver Creek Rd
Ste 103
Bullhead City, AZ 86442
2020 Silver Creek Rd
Bullhead City, AZ 86442
Phone (928) 754-1804
3931 N Stockton Hill Rd
Kingman, AZ 86409
Phone (928) 385-7100
1753 Airway Ave
Kingman, AZ 86409
Phone (928) 757-4359
3931 N Stockton Hill Rd
Ste Ab
Kingman, AZ 86409
2139 Airway Ave
Ste A
Kingman, AZ 86409
Phone (928) 662-9302
309 Lake Havasu Ave S
Ste Ab
Lake Havasu City, AZ 86403
2082 Mesquite Ave
Ste 100
Lake Havasu City, AZ 86403
2082 Mesquite Ave
Lake Havasu City, AZ 86403
309 Lake Havasu Ave S
Ste 100
Lake Havasu City, AZ 86403
Phone (928) 302-1964
309 Lake Havasu Ave S
Ste A
Lake Havasu City, AZ 86403
309 Lake Havasu Ave S
Ste 204
Lake Havasu City, AZ 86403
2082 Mesquite Ave
Ste A
Lake Havasu City, AZ 86403
2849 Maricopa Ave
Lake Havasu City, AZ 86406
1741 Mesquite Ave
Ste 100A
Lk Havasu Cty, AZ 86403
Phone (928) 733-6351
1840 Mesquite Ave
Ste F
Lk Havasu Cty, AZ 86403
309 Lake Havasu Ave S
Ste 102
Lk Havasu Cty, AZ 86403
Phone (928) 302-1964
2082 Mesquite Ave
Ste 100A
Lk Havasu Cty, AZ 86403
Phone (928) 453-2828
1012 S Joshua Ave
Parker, AZ 85344
3259 N Windsong Dr
Ste A
Prescott Vly, AZ 86314
Phone (928) 453-6855
Interoperability endpoints
- https://api.platform.athenahealth.com/3291/brand/1/csg/1/fhir/r4
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Cardiovascular Disease Physician |
207RC0000X | 44211 | AZ | |
| Interventional Cardiology Physician |
207RI0011X | 44211 | AZ | Yes |
Addresses
Primary practice location
1741 Mesquite Ave
Suite A100
Lake Havasu City, AZ 86403-5695
Mailing address
PO Box 3539
Lake Havasu City, AZ 86405-3539
Phone (928) 453-2727
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| P-1663566-8 | Other | AZ | ARIZONA CORPORATION COMMISSION FILING NUMBER |
| 604490 | Medicaid | AZ |
Other providers in Lake Havasu City, AZ
- Lake Havasu Too, LLC
- Lake Havasu Unified School Distrct
- Lake Havasu Unified School District #1
- Lake View Terrace Management LLC
- Lake View Terrace Memory Care
- Lakeside Neurology LLC
- Lakeside Orthopedic Institute LLC
- Lakeside Orthopedic Institute LLC
- Lakeside Orthopedic Institute LLC
- Lakeside Orthopedic Institute LLC
All providers in Lake Havasu City, AZ · Interventional Cardiology Physician in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 20, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.