Basic Information
| Provider Information | |||||||||
| NPI: | 1730410408 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VASCULAR SPECIALTY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8888 SUMMA AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257694493 | ||||||||
| FaxNumber: | 2257663144 | ||||||||
| Practice Location | |||||||||
| Address1: | 8888 SUMMA AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257694493 | ||||||||
| FaxNumber: | 2257663144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2257694493 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MHA | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | DR2923 | 01 | LA | RAILROAD MEDICARE | OTHER | 1795445 | 05 | LA | MEDICAID |