Healthcare Provider Details

I. General information

NPI: 1558405639
Provider Name (Legal Business Name): LEWIS & KLANCKE CARDIOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 09/07/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 SAXON BLVD SUITE 101-C
ORANGE CITY FL
32763-8305
US

IV. Provider business mailing address

695 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2321
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-5485
  • Fax: 386-775-0761
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 Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHLEEN T PHILLIPS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 386-258-8722