Basic Information
Provider Information | |||||||||
NPI: | 1033152822 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA HEART AND VASCULAR SURGEONS, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3130 | ||||||||
Address2: |   | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344783130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3528678311 | ||||||||
FaxNumber: | 3526225771 | ||||||||
Practice Location | |||||||||
Address1: | 1511 SW 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344716505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3528678311 | ||||||||
FaxNumber: | 3526225771 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 01/14/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WIDDIS | ||||||||
AuthorizedOfficialFirstName: | TREVA | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3528678311 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 378057100 | 05 | FL |   | MEDICAID | 72180 | 01 | FL | BCBS OF FLORIDA | OTHER |