Provider Demographics
NPI:1992191910
Name:ATLANTIC HEART AND VASCULAR SPECIALISTS, INC
Entity Type:Organization
Organization Name:ATLANTIC HEART AND VASCULAR SPECIALISTS, INC
Other - Org Name:CARDEX CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHAWAR
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAIKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-296-9933
Mailing Address - Street 1:PO BOX 551107
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1107
Mailing Address - Country:US
Mailing Address - Phone:904-296-9933
Mailing Address - Fax:904-930-4175
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:STE 303
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-296-9933
Practice Address - Fax:904-930-4175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIN815AMedicare PIN
FL006718700Medicaid
FLGP684ZMedicare PIN