Healthcare Provider Details

I. General information

NPI: 1518552447
Provider Name (Legal Business Name): CENTER FOR VASCULAR MEDICINE AL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 ROSS CLARK CIR
DOTHAN AL
36303-3040
US

IV. Provider business mailing address

7474 GREENWAY CENTER DR STE 900
GREENBELT MD
20770-3504
US

V. Phone/Fax

Practice location:
  • Phone: 301-486-4690
  • Fax: 301-441-8809
Mailing address:
  • Phone: 301-982-2000
  • Fax: 301-982-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD KENNEDY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PA-C
Phone: 301-982-2000