Provider Demographics
NPI:1023035862
Name:KSC CARDIOLOGY PA
Entity Type:Organization
Organization Name:KSC CARDIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KOLLAGUNAT
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHANDRASEKHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-294-5505
Mailing Address - Street 1:320 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881
Mailing Address - Country:US
Mailing Address - Phone:863-508-1101
Mailing Address - Fax:863-299-6158
Practice Address - Street 1:320 1ST ST. N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-508-1101
Practice Address - Fax:863-299-6158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2930Medicare ID - Type Unspecified