Basic Information
| Provider Information | |||||||||
| NPI: | 1720226772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOLOGY ASSOCIATES OF GAINESVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4645 NW 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523751212 | ||||||||
| FaxNumber: | 3523714650 | ||||||||
| Practice Location | |||||||||
| Address1: | 922 E CALL ST | ||||||||
| Address2: | |||||||||
| City: | STARKE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320913616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043682300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2009 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | WYCKOFF | ||||||||
| AuthorizedOfficialFirstName: | NORMA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3523751212 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDIOLOGY ASSOCIATES OF GAINESVILLE | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 060906400 | 05 | FL | MEDICAID |