Basic Information
| Provider Information | |||||||||
| NPI: | 1578702775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTEVILLE VASCULAR AND VEIN CENTER, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANDHILLS SURGICAL ASSOCIATES, PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87088 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283047088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104010202 | ||||||||
| FaxNumber: | 9104010210 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 VILLAGE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283044552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104010202 | ||||||||
| FaxNumber: | 9104010210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2009 | ||||||||
| LastUpdateDate: | 10/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | LEKE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9104010202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.