Basic Information
| Provider Information | |||||||||
| NPI: | 1043248859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VASCULAR SPECIALISTS,PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SURGICAL GROUP PSC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7329 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420027329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414300 | ||||||||
| FaxNumber: | 2704414370 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 208R | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414300 | ||||||||
| FaxNumber: | 2704414370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | STUBER | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CODER | ||||||||
| AuthorizedOfficialTelephone: | 2704414376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 65945537 | 05 | KY | MEDICAID |