Basic Information
| Provider Information | |||||||||
| NPI: | 1356359913 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST BOCA EKG READERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 919303 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328919303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547261808 | ||||||||
| FaxNumber: | 9547261820 | ||||||||
| Practice Location | |||||||||
| Address1: | 21644 STATE ROAD 7 | ||||||||
| Address2: | - EKG READERS PANEL | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334281842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547261808 | ||||||||
| FaxNumber: | 9547261820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | FUNT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5614838335 | ||||||||
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| 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 | 34969 | 01 | BLUE CROSS/BLUE SHIELD | OTHER |