Basic Information
| Provider Information | |||||||||
| NPI: | 1962046763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHPARK VASCULAR CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 PALM HARBOR BLVD STE A | ||||||||
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| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346831930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272140462 | ||||||||
| FaxNumber: | 7274740055 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 CHARLES H DIMMOCK PKWY STE 101 | ||||||||
| Address2: | |||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045201764 | ||||||||
| FaxNumber: | 8667813220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2019 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | DEES | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7272140462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.