1528109972 NPI number — FLOWOOD VASCULAR ACCESS CENTER INC

Table of content: (NPI 1528109972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528109972 NPI number — FLOWOOD VASCULAR ACCESS CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLOWOOD VASCULAR ACCESS CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FLOWOOD VASCULAR ACCESS, LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528109972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 416471
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-6471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-644-8900
Provider Business Mailing Address Fax Number:
484-924-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 LAKELAND SQUARE EXT STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-7607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-936-0890
Provider Business Practice Location Address Fax Number:
601-936-0891
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KLEIN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
601-981-1610

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01453071 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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