1932167269 NPI number — VASCULAR INSTITUTE OF GEORGIA, PC

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 1932167269 NPI number — VASCULAR INSTITUTE OF GEORGIA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VASCULAR INSTITUTE OF GEORGIA, PC
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:
6
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:
1932167269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5669 PEACHTREE DUNWOODY RD NE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30342-1786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-256-0404
Provider Business Mailing Address Fax Number:
404-847-0423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5669 PEACHTREE DUNWOODY RD NE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-256-0404
Provider Business Practice Location Address Fax Number:
404-847-0423
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITTENTHAL
Authorized Official First Name:
MARK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
404-256-0404

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: 1033184767 . This is a "J. MARK RHEUDASIL" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00216466H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1861466955 . This is a "MARK G. COAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00460039E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376517300 . This is a "ALAN KOORNICK" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1528028925 . This is a "MICHAEL D. CLARK" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00206005I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1629038476 . This is a "PETER H'DOUBLER JR." identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598739559 . This is a "MARK MITTENTHAL" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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