MEDICARE: FLORIDA HEART & VASCULAR GROUP, PA

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1225284391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA HEART & VASCULAR GROUP, PA

Provider Business Mailing Address
First Line	:	201 LAGRANDE BLVD
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-1303
Country	:	US
Telephone Number	:	352-753-0606
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 LAGRANDE BLVD
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-1303
Country	:	US
Telephone Number	:	352-753-0606
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	REGINA INGRAM
Credential	:
Telephone Number	:	352-728-6808

Provider Enumeration Date	:	08/08/2008
Last Update Date	:	08/08/2008

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