Healthcare Provider Details

I. General information

NPI: 1861933178
Provider Name (Legal Business Name): SOUTHWEST ATLANTA VASCULAR CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 PRINCETON LAKES WAY SW SUITE 314
ATLANTA GA
30331-5589
US

IV. Provider business mailing address

9140 CORSEA DEL FONTANA WAY
NAPLES FL
34109-4397
US

V. Phone/Fax

Practice location:
  • Phone: 404-349-7770
  • Fax: 404-349-7778
Mailing address:
  • Phone: 239-597-2010
  • Fax: 239-597-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA MCNAMARA
Title or Position: EVP
Credential:
Phone: 239-597-2010