Healthcare Provider Details

I. General information

NPI: 1023035862
Provider Name (Legal Business Name): KSC CARDIOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 1ST ST. N
WINTER HAVEN FL
33881
US

IV. Provider business mailing address

320 1ST ST N
WINTER HAVEN FL
33881
US

V. Phone/Fax

Practice location:
  • Phone: 863-508-1101
  • Fax: 863-299-6158
Mailing address:
  • Phone: 863-508-1101
  • Fax: 863-299-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME64020
License Number StateFL

VIII. Authorized Official

Name: DR. KOLLAGUNAT S CHANDRASEKHAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 863-294-5505