1689629404 NPI number — FMC CARDIOLOGY PANEL LLC

Table of content: (NPI 1689629404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689629404 NPI number — FMC CARDIOLOGY PANEL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FMC CARDIOLOGY PANEL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689629404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 918566
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-8566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-726-1808
Provider Business Mailing Address Fax Number:
954-726-1820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 W OAKLAND PARK BLVD
Provider Second Line Business Practice Location Address:
EKG & ECHO READERS PANEL
Provider Business Practice Location Address City Name:
LAUDERDALE LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33313-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-726-1808
Provider Business Practice Location Address Fax Number:
957-726-1820
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
URBANDT
Authorized Official First Name:
PABLO
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-587-4112

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 45986 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 013166300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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