MEDICARE: ADVANCED CARDIAC SCREENING, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	OS0005851	FL

General Provider Information

NPI Number	:	1033499280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED CARDIAC SCREENING, PLLC

Provider Business Mailing Address
First Line	:	1311 MAGNOLIA BAY CT
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-6472
Country	:	US
Telephone Number	:	407-765-0732
Fax Number	:	407-599-6982

Provider Business Practice Location Address
First Line	:	13000 AVALON LAKE DR
Second Line	:	SUITE 100
City	:	ORLANDO
State	:	FL
Zip	:	32828-6434
Country	:	US
Telephone Number	:	321-235-0970
Fax Number	:	321-235-0971

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. BRIAN KELLY
Credential	:	D.O.
Telephone Number	:	407-765-0732

Provider Enumeration Date	:	08/19/2011
Last Update Date	:	08/19/2011

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