Basic Information
| Provider Information | |||||||||
| NPI: | 1518338565 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED VASCULAR CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4516 E HIGHWAY 20 | ||||||||
| Address2: | SUITE 226 | ||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325789755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056625200 | ||||||||
| FaxNumber: | 3052847913 | ||||||||
| Practice Location | |||||||||
| Address1: | 2010 LEWIS TURNER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325471352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056625200 | ||||||||
| FaxNumber: | 3052847913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2015 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL CLAIM SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8505438960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CIMCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1063852192 | 01 | NPI | OTHER | 14V4Q | 01 | BC | OTHER | 011996100 | 05 | FL | MEDICAID |