MEDICARE: VENICE CARDIOVASCULAR ASSOCIATES PL

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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	34655	OTHER	FL	BCBS OF FLORIDA

General Provider Information

NPI Number	:	1316982473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VENICE CARDIOVASCULAR ASSOCIATES PL

Provider Business Mailing Address
First Line	:	700 DOCTORS CT
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-7314
Country	:	US
Telephone Number	:	352-787-9838
Fax Number	:	352-787-8705

Provider Business Practice Location Address
First Line	:	706 THE RIALTO
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34285-3524
Country	:	US
Telephone Number	:	941-484-8004
Fax Number	:	941-484-8869

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TREVA D. WIDDIS
Credential	:
Telephone Number	:	352-787-9838

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	06/05/2020

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