Provider Demographics
NPI:1750699815
Name:MID-FLORIDA INTERVENTIONAL CARDIOLOGY PHYSICIAN SERVICES LLC
Entity type:Organization
Organization Name:MID-FLORIDA INTERVENTIONAL CARDIOLOGY PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-292-4359
Mailing Address - Street 1:134 ARIANA AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-3319
Mailing Address - Country:US
Mailing Address - Phone:863-292-4359
Mailing Address - Fax:863-968-0653
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-292-4652
Practice Address - Fax:863-292-4653
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID- FLORIDA PHYSICIAN SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty