Provider Demographics
NPI:1558405639
Name:LEWIS & KLANCKE CARDIOLOGY PA
Entity Type:Organization
Organization Name:LEWIS & KLANCKE CARDIOLOGY PA
Other - Org Name:DAYTONA HEART GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-258-8722
Mailing Address - Street 1:695 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2321
Mailing Address - Country:US
Mailing Address - Phone:386-258-8722
Mailing Address - Fax:386-258-8659
Practice Address - Street 1:938 SAXON BLVD
Practice Address - Street 2:SUITE 101-C
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8305
Practice Address - Country:US
Practice Address - Phone:386-774-5485
Practice Address - Fax:386-775-0761
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEWIS & KLANCKE CARDIOLOGY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378998500Medicaid