1861693616 NPI number — CARDIOLOGY ASSOCIATES OF POLK COUNTY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861693616 NPI number — CARDIOLOGY ASSOCIATES OF POLK COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDIOLOGY ASSOCIATES OF POLK COUNTY
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:
1861693616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 93254
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33804-3254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-682-8401
Provider Business Mailing Address Fax Number:
863-802-9611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1417 LAKELAND HILLS BLVD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33805-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-682-8401
Provider Business Practice Location Address Fax Number:
863-802-9611
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TALIT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
863-682-8401

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME87246 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 062994400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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