Provider Demographics
NPI:1366478109
Name:ASANTE-KORANG EDWARDS GIROUD MARTINEZ MCCORMACK & SUH MD PA
Entity Type:Organization
Organization Name:ASANTE-KORANG EDWARDS GIROUD MARTINEZ MCCORMACK & SUH MD PA
Other - Org Name:PEDIATRIC CARDIOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-767-4200
Mailing Address - Street 1:880 6TH ST S
Mailing Address - Street 2:280
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4827
Mailing Address - Country:US
Mailing Address - Phone:727-767-4200
Mailing Address - Fax:727-767-8047
Practice Address - Street 1:840 DR MLKING JR ST NO
Practice Address - Street 2:400
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705
Practice Address - Country:US
Practice Address - Phone:727-767-4200
Practice Address - Fax:727-767-8047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21826Medicare ID - Type Unspecified