Healthcare Provider Details

I. General information

NPI: 1912136524
Provider Name (Legal Business Name): GEORGIA VASCULAR INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3886 PRINCETON LAKES WAY SW STE 100
ATLANTA GA
30331-5511
US

IV. Provider business mailing address

3886 PRINCETON LAKES WAY SW STE 100
ATLANTA GA
30331-5511
US

V. Phone/Fax

Practice location:
  • Phone: 770-506-4007
  • Fax: 678-623-3543
Mailing address:
  • Phone: 770-506-4007
  • Fax: 678-623-3543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: HOLLY FARROW
Title or Position: COO
Credential:
Phone: 770-506-4007