Basic Information
| Provider Information | |||||||||
| NPI: | 1558420778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA VASCULAR SPECIALISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 54888 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303080888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043509505 | ||||||||
| FaxNumber: | 4043501611 | ||||||||
| Practice Location | |||||||||
| Address1: | 1718 PEACHTREE ST NW | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303092452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043509505 | ||||||||
| FaxNumber: | 4043501611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | POINDEXTER | ||||||||
| AuthorizedOfficialFirstName: | LAVERNE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4043509505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA VASCULAR HOLDING CORPORATION PC | ||||||||
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| AuthorizedOfficialCredential: | RN, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.