Basic Information
| Provider Information | |||||||||
| NPI: | 1750699815 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-FLORIDA INTERVENTIONAL CARDIOLOGY PHYSICIAN SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 ARIANA AVE | ||||||||
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| City: | AUBURNDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338233319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632924359 | ||||||||
| FaxNumber: | 8639680653 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632924652 | ||||||||
| FaxNumber: | 8632924653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2010 | ||||||||
| LastUpdateDate: | 09/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | GRINER | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8632924359 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MID- FLORIDA PHYSICIAN SERVICES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.