1992132807 NPI number — ADVANCED VASCULAR RESOURCES OF JOHNSTOWN LLC

Table of content: (NPI 1992132807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992132807 NPI number — ADVANCED VASCULAR RESOURCES OF JOHNSTOWN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED VASCULAR RESOURCES OF JOHNSTOWN 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:
1992132807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20032 NORTHVILLE HILLS TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20147-7020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-994-6655
Provider Business Mailing Address Fax Number:
571-291-2752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1027 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15906-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-619-0945
Provider Business Practice Location Address Fax Number:
855-341-0781
Provider Enumeration Date:
10/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HADEED
Authorized Official First Name:
SAMIR
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
814-619-0945

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  MD073567L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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