Provider Demographics
NPI:1528206638
Name:CARDIOLOGY ASSOCIATES OF GAINESVILLE
Entity Type:Organization
Organization Name:CARDIOLOGY ASSOCIATES OF GAINESVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WYCKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-375-1212
Mailing Address - Street 1:4645 NW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4524
Mailing Address - Country:US
Mailing Address - Phone:352-375-1212
Mailing Address - Fax:352-371-4650
Practice Address - Street 1:3140 NW MEDICAL CENTER LN STE 140
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4735
Practice Address - Country:US
Practice Address - Phone:386-487-0118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARDIOLOGY ASSOCIATES OF GAINESVILLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-27
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060906400Medicaid
FL060906400Medicaid