Basic Information
| Provider Information | |||||||||
| NPI: | 1023397213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA VASCULAR CLINIC AT SAINT JOSEPH'S, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1838 AMERICAN WAY | ||||||||
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| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709957622 | ||||||||
| FaxNumber: | 7709957854 | ||||||||
| Practice Location | |||||||||
| Address1: | 5671 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042560170 | ||||||||
| FaxNumber: | 4042562998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2011 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6788435773 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
No ID Information.