MEDICARE: NORTHEAST ATLANTA VASCULAR CARE, 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1649791641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST ATLANTA VASCULAR CARE, LLC

Provider Business Mailing Address
First Line	:	9140 CORSEA DEL FONTANA WAY
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34109-4397
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 DUNWOODY PARK STE 130
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-6714
Country	:	US
Telephone Number	:	404-554-2080
Fax Number	:	404-554-8021

Authorized Official
Title or Position	:	OFFICER AND AUTHORIZED OFFICIAL
Name	:	JENNIFER BOYD BALDOCK
Credential	:
Telephone Number	:	615-234-5954

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	02/06/2026

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