Healthcare Provider Details

I. General information

NPI: 1790871028
Provider Name (Legal Business Name): HEART OF FLORIDA OB/GYN ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 NORTH BLVD W
DAVENPORT FL
33837-8990
US

IV. Provider business mailing address

PO BOX 667
DAVENPORT FL
33836-0667
US

V. Phone/Fax

Practice location:
  • Phone: 863-421-7600
  • Fax: 863-421-7551
Mailing address:
  • Phone: 863-421-7600
  • Fax: 863-421-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MARCI KAY HARRIS
Title or Position: OFFC MGR
Credential:
Phone: 863-421-7600