Healthcare Provider Details

I. General information

NPI: 1437281102
Provider Name (Legal Business Name): FLORIDA HEART & VASCULAR MULTI SPECIALTY GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 E DIXIE AVE
LEESBURG FL
34748-6014
US

IV. Provider business mailing address

802 E DIXIE AVE
LEESBURG FL
34748-6014
US

V. Phone/Fax

Practice location:
  • Phone: 352-787-1324
  • Fax: 352-360-0668
Mailing address:
  • Phone: 352-728-6808
  • Fax: 352-728-1751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: REGINA INGRAM
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 352-728-6808