Provider Demographics
NPI:1144420852
Name:PALM BEACH CARDIOVASCULAR CLINIC LLC
Entity Type:Organization
Organization Name:PALM BEACH CARDIOVASCULAR CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTO
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-627-2210
Mailing Address - Street 1:601 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2788
Mailing Address - Country:US
Mailing Address - Phone:561-627-2210
Mailing Address - Fax:561-627-5850
Practice Address - Street 1:601 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2788
Practice Address - Country:US
Practice Address - Phone:561-627-2210
Practice Address - Fax:561-627-5850
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALM BEACH CARDIOVASCULAR CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21776207RC0000X, 207RC0001X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21776OtherMEDICARE NUMBER