Basic Information
| Provider Information | |||||||||
| NPI: | 1477569291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTRACOASTAL CARDIAC SERVICES GEN PTRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 NW 66TH AVE | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333134582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547261808 | ||||||||
| FaxNumber: | 9547261820 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 NW 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334452519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617361200 | ||||||||
| FaxNumber: | 5617421919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 08/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | ANESTA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617361200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | CI9848 | 01 | FL | RAILROAD MEDICARE | OTHER | 062451900 | 05 | FL | MEDICAID | 72193 | 01 | FL | BCBS | OTHER |