Provider Demographics
NPI:1932105558
Name:FLORIDA HEART GROUP
Entity Type:Organization
Organization Name:FLORIDA HEART GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-894-4474
Mailing Address - Street 1:1613 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1849
Mailing Address - Country:US
Mailing Address - Phone:407-894-4474
Mailing Address - Fax:407-894-7136
Practice Address - Street 1:1613 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1849
Practice Address - Country:US
Practice Address - Phone:407-894-4474
Practice Address - Fax:407-894-7136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0016884207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5019744OtherAETNA
FLCI0696OtherRRR
FL99800OtherBCBS
FL99800Medicare PIN