Basic Information
| Provider Information | |||||||||
| NPI: | 1710425913 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLOWOOD VASCULAR ACCESS ASC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419663 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022419663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 LAKELAND SQUARE EXT | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392327607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017098800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2017 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7183691444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 02558295 | 05 | MS | MEDICAID |