MEDICARE: CARDIOVASCULAR CLINIC OF EAST FORT LAUDERDALE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1114606480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOVASCULAR CLINIC OF EAST FORT LAUDERDALE LLC

Provider Business Mailing Address
First Line	:	40 VALLEY STREAM PKWY STE 100
Second Line	:
City	:	MALVERN
State	:	PA
Zip	:	19355-1407
Country	:	US
Telephone Number	:	610-644-8900
Fax Number	:	484-924-0053

Provider Business Practice Location Address
First Line	:	1925 NE 45TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-5121
Country	:	US
Telephone Number	:	954-651-9847
Fax Number	:

Authorized Official
Title or Position	:	CHIEF CLINICAL OFFICER
Name	:	KELLY BEMIS
Credential	:
Telephone Number	:	610-644-8900

Provider Enumeration Date	:	07/14/2023
Last Update Date	:	07/14/2023

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