1841789914 NPI number — MILNER VEIN AND VASCULAR LLC

Table of content: (NPI 1841789914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841789914 NPI number — MILNER VEIN AND VASCULAR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILNER VEIN AND VASCULAR 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:
1841789914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 HILLANDALE DR STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITHONIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30058-4120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-580-1149
Provider Business Mailing Address Fax Number:
770-557-1347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5700 HILLANDALE DR STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-580-1149
Provider Business Practice Location Address Fax Number:
770-557-1347
Provider Enumeration Date:
05/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MILNER
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
PATTERSON
Authorized Official Title or Position:
MEDICAL PHYSICIAN/OWNER
Authorized Official Telephone Number:
678-580-1149

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  59562 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 633601408D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59562 . This is a "GEORGIA LICENSE NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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