Basic Information
| Provider Information | |||||||||
| NPI: | 1366595068 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACHTREE VASCULAR SPECIALISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 SOUTHCREST DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709969945 | ||||||||
| FaxNumber: | 7709967355 | ||||||||
| Practice Location | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283106118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109071035 | ||||||||
| FaxNumber: | 9109079468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCDEVITT | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7709969945 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.