Basic Information
| Provider Information | |||||||||
| NPI: | 1265616627 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VVMC DIVERSIFIED SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVANTI CARDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848997 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022848997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 108 SOUTH FRONTAGE ROAD WEST | ||||||||
| Address2: | 206 | ||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761110 | ||||||||
| FaxNumber: | 9704767319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 12/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | CREVLING | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9704797238 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VVMC DIVERSIFIED SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.