Provider Demographics
NPI:1922053115
Name:RIVERVIEW CARDIAC SURGERY P A
Entity Type:Organization
Organization Name:RIVERVIEW CARDIAC SURGERY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLHOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:727-647-1188
Mailing Address - Street 1:PO BOX 15088
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34280-5088
Mailing Address - Country:US
Mailing Address - Phone:941-744-2640
Mailing Address - Fax:941-744-2650
Practice Address - Street 1:5304 4TH AVENUE CIR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5624
Practice Address - Country:US
Practice Address - Phone:941-744-2640
Practice Address - Fax:941-744-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208G00000X, 208G00000X
FLME78246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID #
FLG93502Medicare UPIN
FLE36305Medicare UPIN
FLS72162Medicare UPIN