MEDICARE: CARDIOVASCULAR CONSULTANTS OF ST AUGUSTINE PL

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	207RC0000X	Cardiovascular Disease Physician	ME85299	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386728848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOVASCULAR CONSULTANTS OF ST AUGUSTINE PL

Provider Business Mailing Address
First Line	:	3501B N PONCE DE LEON BLVD PMB 392
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32084-1400
Country	:	US
Telephone Number	:	904-823-8809
Fax Number	:	904-823-8851

Provider Business Practice Location Address
First Line	:	300 HEALTH PARK BLVD STE 5010
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32086-3705
Country	:	US
Telephone Number	:	904-823-8809
Fax Number	:	904-823-8851

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALI TUTAR
Credential	:	M.D.
Telephone Number	:	904-823-8809

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	04/02/2018

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