Provider Demographics
NPI:1578094629
Name:CONGENITAL HEART CARE CENTER OF FLORIDA
Entity Type:Organization
Organization Name:CONGENITAL HEART CARE CENTER OF FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AURELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:407-862-1010
Mailing Address - Street 1:360 N LAKE SYBELIA DR
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4720
Mailing Address - Country:US
Mailing Address - Phone:407-862-1010
Mailing Address - Fax:407-862-1016
Practice Address - Street 1:425 S HUNT CLUB BLVD
Practice Address - Street 2:STE 1001
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4947
Practice Address - Country:US
Practice Address - Phone:407-862-1010
Practice Address - Fax:407-862-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME864552080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005948200 091812Medicaid
FL005948200 091812Medicaid