Provider Demographics
NPI:1730242173
Name:CARDIOLOG ASSOCIATES OF GAINESVILLE
Entity type:Organization
Organization Name:CARDIOLOG ASSOCIATES OF GAINESVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WYCKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-377-1212
Mailing Address - Street 1:4645 NW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4524
Mailing Address - Country:US
Mailing Address - Phone:352-377-1212
Mailing Address - Fax:
Practice Address - Street 1:922 E CALL ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3616
Practice Address - Country:US
Practice Address - Phone:904-368-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121OtherBCBS PROVIDER #
FL121OtherBCBS PROVIDER #