Provider Demographics
NPI:1679508063
Name:CARDIOVASCULAR ASSOCIATES OF LAKE COUNTY, PA
Entity Type:Organization
Organization Name:CARDIOVASCULAR ASSOCIATES OF LAKE COUNTY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-742-1171
Mailing Address - Street 1:1879 NIGHTINGALE LANE
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778
Mailing Address - Country:US
Mailing Address - Phone:352-742-1171
Mailing Address - Fax:352-742-7241
Practice Address - Street 1:1879 NIGHTINGALE LANE
Practice Address - Street 2:SUITE C-1
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-742-1171
Practice Address - Fax:352-742-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374579100Medicaid
FL374579100Medicaid