Provider Demographics
NPI:1689395675
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:
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:386-258-9443
Practice Address - Street 1:655 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2324
Practice Address - Country:US
Practice Address - Phone:386-258-8722
Practice Address - Fax:386-258-8659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEWIS & KLANCKE CARDIOLOGY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-07
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99279OtherMEDICARE
FL378998500Medicaid