Provider Demographics
NPI:1548981947
Name:LEWIS & KLANCKE CARDIOLOGY, P.A.
Entity type:Organization
Organization Name:LEWIS & KLANCKE CARDIOLOGY, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-258-8722
Mailing Address - Street 1:695 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2321
Mailing Address - Country:US
Mailing Address - Phone:386-258-8722
Mailing Address - Fax:386-258-9443
Practice Address - Street 1:1404 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-2720
Practice Address - Country:US
Practice Address - Phone:386-265-5926
Practice Address - Fax:386-265-5928
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEWIS & KLANCKE CARDIOLOGY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-06
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119006900Medicaid
FL99279OtherMEDICARE