=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376264788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEWIS & KLANCKE CARDIOLOGY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2022
-----------------------------------------------------
Last Update Date | 10/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 HALIFAX CROSSING BLVD STE 220
-----------------------------------------------------
City | DELTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32725-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-774-5485
-----------------------------------------------------
Fax | 386-775-0761
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 695 N CLYDE MORRIS BLVD
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-2321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-258-8722
-----------------------------------------------------
Fax | 386-258-9443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | KATHLEEN T PHILLIPS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-258-8722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207UN0901X
-----------------------------------------------------
Taxonomy Name | Nuclear Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------