Healthcare Provider Details

I. General information

NPI: 1134546542
Provider Name (Legal Business Name): THORACIC AND VASCULAR SURGEONS OF GAINESVILLE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 NW 64TH TER
GAINESVILLE FL
32605-4218
US

IV. Provider business mailing address

PO BOX 14655
GAINESVILLE FL
32604-4655
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-8570
  • Fax: 352-331-9095
Mailing address:
  • Phone: 352-331-9095
  • Fax: 352-331-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME94028
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME94028
License Number StateFL

VIII. Authorized Official

Name: RICHARD R PROIA
Title or Position: PRESIDENT
Credential: MD
Phone: 352-416-2628