=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730242173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOLOG ASSOCIATES OF GAINESVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 922 E CALL ST
-----------------------------------------------------
City | STARKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32091-3616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-368-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4645 NW 8TH AVE
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32605-4524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-377-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE MANAGER
-----------------------------------------------------
Name | MRS. NORMA J WYCKOFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-377-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------