Provider Demographics
NPI:1225053176
Name:SPACE COAST CARDIOLOGY CONSULTANTS
Entity Type:Organization
Organization Name:SPACE COAST CARDIOLOGY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-635-8304
Mailing Address - Street 1:7139 NORTH HIGHWAY US # 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOHN
Mailing Address - State:FL
Mailing Address - Zip Code:32927-5094
Mailing Address - Country:US
Mailing Address - Phone:321-635-8304
Mailing Address - Fax:321-635-8252
Practice Address - Street 1:7139 NORTH HIGHWAY US # 1
Practice Address - Street 2:
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-5094
Practice Address - Country:US
Practice Address - Phone:321-635-8304
Practice Address - Fax:321-635-8252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055762174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCL3045OtherRAILROAD MEDICARE
FLCL3045OtherRAILROAD MEDICARE