Provider Demographics
NPI:1598016362
Name:FLORIDA HEART & VASCULAR MULTI SPECIALTY GROUP, PA
Entity Type:Organization
Organization Name:FLORIDA HEART & VASCULAR MULTI SPECIALTY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-728-6808
Mailing Address - Street 1:511 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7326
Mailing Address - Country:US
Mailing Address - Phone:352-728-6808
Mailing Address - Fax:352-728-1743
Practice Address - Street 1:802 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6014
Practice Address - Country:US
Practice Address - Phone:352-728-6808
Practice Address - Fax:352-728-1743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108692207R00000X
FLME 108692207RN0300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14JE3OtherBCBS
FL14JE3OtherBCBS