1922549237 NPI number — SOUTHEAST ATLANTA VASCULAR CARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922549237 NPI number — SOUTHEAST ATLANTA VASCULAR CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST ATLANTA VASCULAR CARE, LLC
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:
Provider Other Organization Name Type Code:
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:
1922549237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9140 CORSEA DEL FONTANA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34109-4397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-597-2010
Provider Business Mailing Address Fax Number:
239-597-2313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5461 HILLANDALE DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30058-4841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-981-8477
Provider Business Practice Location Address Fax Number:
770-981-8908
Provider Enumeration Date:
03/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MCNAMARA
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP
Authorized Official Telephone Number:
239-597-2010

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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