Basic Information
| Provider Information | |||||||||
| NPI: | 1043773161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EFFINGHAM VASCULAR CENTER, LLC | ||||||||
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| OtherOrganizationName: | EFFINGHAM VASCULAR CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 459 HIGHWAY 119 SOUTH | ||||||||
| Address2: | ATTN.: CREDENTIALING | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127540175 | ||||||||
| FaxNumber: | 9127542570 | ||||||||
| Practice Location | |||||||||
| Address1: | 613 TOWNE PARK DR W STE 204 | ||||||||
| Address2: | |||||||||
| City: | RINCON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313265183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128266771 | ||||||||
| FaxNumber: | 9122955605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2019 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAKER-WITT | ||||||||
| AuthorizedOfficialFirstName: | FRAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9127540160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | RN, MBA, LNHA | ||||||||
| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.