Provider Demographics
NPI:1356733695
Name:EKG PANEL OF BLAKE
Entity type:Organization
Organization Name:EKG PANEL OF BLAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-365-8532
Mailing Address - Street 1:PO BOX 25548
Mailing Address - Street 2:EKG PANEL OF BLAKE
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2548
Mailing Address - Country:US
Mailing Address - Phone:941-321-2830
Mailing Address - Fax:504-588-2165
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:BLAKE MEDICAL CENTER
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-321-2830
Practice Address - Fax:504-588-2165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty