Provider Demographics
NPI:1699769042
Name:FLORIDA HEART & VASCULAR MULTI SPECIALTY GROUP PA
Entity type:Organization
Organization Name:FLORIDA HEART & VASCULAR MULTI SPECIALTY GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAUNDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-728-6808
Mailing Address - Street 1:511 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7326
Mailing Address - Country:US
Mailing Address - Phone:352-728-6808
Mailing Address - Fax:352-728-1743
Practice Address - Street 1:511 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7326
Practice Address - Country:US
Practice Address - Phone:352-728-6808
Practice Address - Fax:352-728-1743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21798OtherBCBS FLORIDA
FL255260400Medicaid
773114OtherMAILHANDLERS
695956OtherTUFTS
CN9333OtherGBA RR PALMETTO
7914953OtherMAMSI
7914953OtherMAMSI
=========OtherMEDICAL MUTUAL
695956OtherTUFTS