Basic Information
| Provider Information | |||||||||
| NPI: | 1316982473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VENICE CARDIOVASCULAR ASSOCIATES PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 DOCTORS CT | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347487314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527879838 | ||||||||
| FaxNumber: | 3527878705 | ||||||||
| Practice Location | |||||||||
| Address1: | 706 THE RIALTO | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342853524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414848004 | ||||||||
| FaxNumber: | 9414848869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | WIDDIS | ||||||||
| AuthorizedOfficialFirstName: | TREVA | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3527879838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/05/2020 | ||||||||
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 | 267915900 | 05 | FL | MEDICAID | 34655 | 01 | FL | BCBS OF FLORIDA | OTHER |