Healthcare Provider Details

I. General information

NPI: 1255683470
Provider Name (Legal Business Name): GEORGIA INTERVENTIONAL AND VASCULAR SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 19TH ST NW STE 2240
ATLANTA GA
30363-1139
US

IV. Provider business mailing address

2015 SPRING RD STE 300
OAK BROOK IL
60523-3944
US

V. Phone/Fax

Practice location:
  • Phone: 404-532-1564
  • Fax: 404-532-1565
Mailing address:
  • Phone: 630-725-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042261
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number042261
License Number StateGA

VIII. Authorized Official

Name: CYNTHIA JONES
Title or Position: CREDENTIALING
Credential:
Phone: 630-725-2737