Provider Demographics
NPI:1669710141
Name:FLORIDA HEART & VASCULAR CARE, PLLC
Entity type:Organization
Organization Name:FLORIDA HEART & VASCULAR CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:CHRISTIANE
Authorized Official - Last Name:THEILADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-237-7353
Mailing Address - Street 1:146 PALM COAST RESORT BLVD
Mailing Address - Street 2:SUITE 806
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-1812
Mailing Address - Country:US
Mailing Address - Phone:615-400-0380
Mailing Address - Fax:
Practice Address - Street 1:120 CYPRESS EDGE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8453
Practice Address - Country:US
Practice Address - Phone:386-586-4410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0046GOtherBCBS
FL008378300Medicaid
FLDT6579OtherRAILROAD
FLHB766AMedicare PIN