Healthcare Provider Details

I. General information

NPI: 1669589263
Provider Name (Legal Business Name): LEWIS & KLANCKE CARDIOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

695 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114
US

V. Phone/Fax

Practice location:
  • Phone: 386-258-8722
  • Fax: 386-258-9443
Mailing address:
  • Phone: 386-258-8722
  • Fax: 386-258-8659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHY PHILLIPS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 386-258-8722