Provider Demographics
NPI:1154453074
Name:FLORIDA HEART & VASCULAR MULTI SPECIALTY GROUP, PA
Entity Type:Organization
Organization Name:FLORIDA HEART & VASCULAR MULTI SPECIALTY GROUP, PA
Other - Org Name:FREDRIC M. DAVIS,DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-728-6808
Mailing Address - Street 1:511 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7326
Mailing Address - Country:US
Mailing Address - Phone:352-728-6808
Mailing Address - Fax:352-728-1751
Practice Address - Street 1:704 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7314
Practice Address - Country:US
Practice Address - Phone:352-326-7850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21798Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER