Basic Information
| Provider Information | |||||||||
| NPI: | 1770832461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLOWOOD VASCULAR ACCESS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 VALLEY STREAM PKWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193551407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 LAKELAND SQUARE EXT STE B | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392327607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017098800 | ||||||||
| FaxNumber: | 6013662887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2012 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | AO | ||||||||
| AuthorizedOfficialTelephone: | 6019811610 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.