Basic Information
| Provider Information | |||||||||
| NPI: | 1467778381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEARWATER CARDIOVASCULAR & INTERVENTIONAL CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 PINELLAS ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274451992 | ||||||||
| FaxNumber: | 7274451993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 MEASE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346956602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277256246 | ||||||||
| FaxNumber: | 7277265865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2010 | ||||||||
| LastUpdateDate: | 04/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | SIMMONS | ||||||||
| AuthorizedOfficialFirstName: | FREDERIC | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7274451992 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 057111300 | 05 | FL | MEDICAID |