Provider Demographics
NPI:1508818592
Name:PARK AVENUE HEART AND VASCULAR CENTER LLC
Entity Type:Organization
Organization Name:PARK AVENUE HEART AND VASCULAR CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-633-2021
Mailing Address - Street 1:562 PARK ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-2918
Mailing Address - Country:US
Mailing Address - Phone:904-633-2021
Mailing Address - Fax:904-633-9793
Practice Address - Street 1:1824 KING ST
Practice Address - Street 2:SUITE 250
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4735
Practice Address - Country:US
Practice Address - Phone:904-388-1820
Practice Address - Fax:904-388-1827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN