1629130851 NPI number — PEACHTREE VASCULAR ASSOCIATES, P.C.

Table of content: (NPI 1629130851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629130851 NPI number — PEACHTREE VASCULAR ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACHTREE VASCULAR ASSOCIATES, P.C.
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:
1629130851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 PEACHTREE ST NE
Provider Second Line Business Mailing Address:
SUITE 1085
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30308-2247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-681-3190
Provider Business Mailing Address Fax Number:
404-681-3193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 PEACHTREE ST NE
Provider Second Line Business Practice Location Address:
SUITE 1085
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30308-2232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-681-3190
Provider Business Practice Location Address Fax Number:
404-681-3193
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SKARDASIS
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-681-3190

Provider Taxonomy Codes

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

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

  • Identifier: 00053633A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 578663 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1013082387 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 17-05841 . This is a "HEALTH FIRST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 253729461 . This is a "CHAMPUS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 020044829 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 212200 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GRP1615 . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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