Basic Information
| Provider Information | |||||||||
| NPI: | 1619912789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOVASCULAR THERAPY ASSOCIATES,INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N. NOB HILL ROAD | ||||||||
| Address2: | SUITE 273 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333241708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865961960 | ||||||||
| FaxNumber: | 3054412144 | ||||||||
| Practice Location | |||||||||
| Address1: | 8900 N KENDALL DR | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331762118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865961960 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 10/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | KATZEN | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3055961960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 259389100 | 05 | FL | MEDICAID |