Provider Demographics
NPI:1114095890
Name:SOUTH COUNTY HEART GROUP INC
Entity Type:Organization
Organization Name:SOUTH COUNTY HEART GROUP INC
Other - Org Name:SOUTH COUNTY HEART CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRERSIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-492-5666
Mailing Address - Street 1:1225 JACARANDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-4521
Mailing Address - Country:US
Mailing Address - Phone:941-492-5666
Mailing Address - Fax:941-497-2331
Practice Address - Street 1:1225 JACARANDA BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-4521
Practice Address - Country:US
Practice Address - Phone:941-492-5666
Practice Address - Fax:941-497-2331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252635200Medicaid
C18929OtherBLUE CROSS
FL257322900Medicaid
FL373654700Medicaid
FLCE0372OtherRAILROAD MEDICARE
FLCE0372OtherRAILROAD MEDICARE