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General NPI Number Information
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NPI Number | 1063131712
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Entity Type | Organization
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Legal Business Name | CARDIOVASCULAR SURGICAL INSTITUTE OF NW FLORIDA, LLC
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Dates
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Enumeration Date | 08/25/2022
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 625 W BALDWIN RD STE D
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City | PANAMA CITY
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State | FL
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Zip | 32405-3359
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Country | US
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Telephone | 210-621-5621
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Fax |
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Provider Business Mailing Address
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Address Line | 13830 SAWYER RANCH RD STE 105
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City | DRIPPING SPRINGS
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State | TX
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Zip | 78620-5514
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Country | US
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Telephone | 210-621-5621
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | KIMBERLEY MCILLWAIN
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Credential |
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Telephone | 609-575-5854
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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