Healthcare Provider Details

I. General information

NPI: 1720247984
Provider Name (Legal Business Name): ADVANCED HEART GROUP PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY SUITE 305
DAYTONA BEACH FL
32117-5168
US

IV. Provider business mailing address

PO BOX 731138
ORMOND BEACH FL
32173-1138
US

V. Phone/Fax

Practice location:
  • Phone: 386-767-9585
  • Fax: 386-767-9769
Mailing address:
  • Phone: 386-767-9585
  • Fax: 386-677-5370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME90030
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME97780
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME79499
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME97780
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberME97780
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME79499
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME90030
License Number StateFL

VIII. Authorized Official

Name: DR. ARTHUR WARREN CROSSMAN
Title or Position: SECRETARY
Credential: MD
Phone: 386-677-7875