Provider Demographics
NPI:1225284391
Name:FLORIDA HEART & VASCULAR GROUP, PA
Entity Type:Organization
Organization Name:FLORIDA HEART & VASCULAR GROUP, PA
Other - Org Name:LEESBURG FAMILY MEDICINE
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 1:201 LAGRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-1303
Mailing Address - Country:US
Mailing Address - Phone:352-753-0606
Mailing Address - Fax:
Practice Address - Street 1:201 LAGRANDE BLVD
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-1303
Practice Address - Country:US
Practice Address - Phone:352-753-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty