Provider Demographics
NPI:1902829393
Name:TAHER KHALIL M D P A
Entity Type:Organization
Organization Name:TAHER KHALIL M D P A
Other - Org Name:CARDIOVASCULAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-673-5441
Mailing Address - Street 1:1425 HAND AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-1135
Mailing Address - Country:US
Mailing Address - Phone:386-673-5404
Mailing Address - Fax:386-673-5480
Practice Address - Street 1:1425 HAND AVE
Practice Address - Street 2:SUITE K
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-1135
Practice Address - Country:US
Practice Address - Phone:386-673-5404
Practice Address - Fax:386-673-5480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81508207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264363400Medicaid
FL78667OtherBC/BS OF FLORIDA
FLG13955Medicare UPIN
FL264363400Medicaid