Basic Information
| Provider Information | |||||||||
| NPI: | 1164948360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART RHYTHM SPECIALISTS AT DAYTONA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 MEMORIAL MEDICAL PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866721023 | ||||||||
| FaxNumber: | 3862632996 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 MEMORIAL MEDICAL PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866721023 | ||||||||
| FaxNumber: | 3862632996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 08/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | YVETTE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CONSULTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3863160955 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 00115440 | 05 | FL | MEDICAID |