MEDICARE: LEWIS & KLANCKE CARDIOLOGY, P.A.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207RC0001X	Clinical Cardiac Electrophysiology Physician
2	207RI0011X	Interventional Cardiology Physician
3	207UN0901X	Nuclear Cardiology Physician
4	207RC0000X	Cardiovascular Disease Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	99279	OTHER	FL	OTHER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205557691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEWIS & KLANCKE CARDIOLOGY, P.A.

Provider Business Mailing Address
First Line	:	695 N CLYDE MORRIS BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-2321
Country	:	US
Telephone Number	:	386-258-8722
Fax Number	:	386-258-9443

Provider Business Practice Location Address
First Line	:	780 DUNLAWTON AVE STE 101
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4252
Country	:	US
Telephone Number	:	386-265-5926
Fax Number	:	386-265-5928

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	KATHLEEN T PHILLIPS
Credential	:
Telephone Number	:	386-258-8722

Provider Enumeration Date	:	09/06/2022
Last Update Date	:	10/03/2023

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Directions to “LEWIS & KLANCKE CARDIOLOGY, P.A. ” Practice Location

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