Basic Information
| Provider Information | |||||||||
| NPI: | 1154701365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART AND VASCULAR ASSOCIATES OF TAMPA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4706 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336774706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132800202 | ||||||||
| FaxNumber: | 8132800203 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 DAVIS BLVD | ||||||||
| Address2: | SUITE 313 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132800202 | ||||||||
| FaxNumber: | 8132800203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2015 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | HAMDAN | ||||||||
| AuthorizedOfficialFirstName: | TALAL | ||||||||
| AuthorizedOfficialMiddleName: | SHAWKI | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8132800202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 009WY | 01 | FL | BLUE CROSS | OTHER | 015515800 | 05 | FL | MEDICAID |