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General NPI Number Information
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NPI Number | 1871879841
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Entity Type | Organization
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Legal Business Name | ADVANCED CARDIAC DIAGNOSTICS LLC
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Dates
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Enumeration Date | 10/22/2011
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Last Update Date | 08/01/2013
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Provider Practice Location Address
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Address Line | 2507 HOLLY POINT RD E
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City | ORANGE PARK
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State | FL
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Zip | 32073-5632
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Country | US
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Telephone | 904-315-2004
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 814
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City | ORANGE PARK
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State | FL
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Zip | 32067-0814
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Country | US
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Telephone | 904-315-2004
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | DR. MICHAEL ANDREW ILLOVSKY
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Credential | MD
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Telephone | 904-315-2004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | ME74432
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License Number State | FL
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