Provider Demographics
NPI:1235323023
Name:LONGWOOD MEDICAL GROUP PA
Entity Type:Organization
Organization Name:LONGWOOD MEDICAL GROUP PA
Other - Org Name:LONGWOOD CARDIOLOGY PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING OFFICE SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHARACTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-767-8200
Mailing Address - Street 1:450 W STATE RD 434
Mailing Address - Street 2:STE 301
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750
Mailing Address - Country:US
Mailing Address - Phone:407-767-8200
Mailing Address - Fax:407-767-0476
Practice Address - Street 1:450 W STATE ROAD 434
Practice Address - Street 2:STE 301
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5187
Practice Address - Country:US
Practice Address - Phone:407-767-8200
Practice Address - Fax:407-767-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2018-05-01
Deactivation Date:2018-04-15
Deactivation Code:
Reactivation Date:2018-05-01
Provider Licenses
StateLicense IDTaxonomies
FLME79324207Q00000X
FLME78066207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2596Medicare PIN