Provider Demographics
NPI:1336192848
Name:CARDIOVASCULAR SPECIALISTS PA
Entity type:Organization
Organization Name:CARDIOVASCULAR SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CECELIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-321-1415
Mailing Address - Street 1:305 N MANGOUSTINE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1004
Mailing Address - Country:US
Mailing Address - Phone:407-321-1415
Mailing Address - Fax:407-321-1597
Practice Address - Street 1:305 N MANGOUSTINE AVE
Practice Address - Street 2:STE 200
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1004
Practice Address - Country:US
Practice Address - Phone:407-321-1415
Practice Address - Fax:407-321-1597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274257800Medicaid
38686OtherBC/BS
FL274257800Medicaid