MEDICARE: ATLANTA VASCULAR AND INTERVENTIONAL RADIOLOGY ASSOCIATE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0204X	Vascular & Interventional Radiology Physician		GA

General Provider Information

NPI Number	:	1144742271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTA VASCULAR AND INTERVENTIONAL RADIOLOGY ASSOCIATE, LLC

Provider Business Mailing Address
First Line	:	3645 MARKETPLACE BLVD STE 130-420
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-5747
Country	:	US
Telephone Number	:	678-519-0334
Fax Number	:	404-920-3430

Provider Business Practice Location Address
First Line	:	4550 JONESBORO RD STE K
Second Line	:
City	:	UNION CITY
State	:	GA
Zip	:	30291-2053
Country	:	US
Telephone Number	:	678-519-0334
Fax Number	:	404-920-3430

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ANISHUA M ROBERTS
Credential	:
Telephone Number	:	678-519-0344

Provider Enumeration Date	:	07/11/2017
Last Update Date	:	07/11/2017

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