Basic Information
| Provider Information | |||||||||
| NPI: | 1104881341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLLIER HEART GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328850001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396590102 | ||||||||
| FaxNumber: | 2396590108 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 9TH ST N | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396590102 | ||||||||
| FaxNumber: | 2396590108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | AXLINE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2396590102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 00793 | 01 | FL | BCBS | OTHER | DE1357 | 01 | FL | RR MEDICARE | OTHER |