=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366795742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST COAST HEART & VASCULAR CENTER, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2012
-----------------------------------------------------
Last Update Date | 04/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 UNIVERSITY BLVD S SUITE 221
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-423-0010
-----------------------------------------------------
Fax | 904-423-0012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 47170
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32247-7170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-423-0010
-----------------------------------------------------
Fax | 904-423-0012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL M. BLUMENTHAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 617-694-1113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------