Healthcare Provider Details

I. General information

NPI: 1841711942
Provider Name (Legal Business Name): MACON VASCULAR CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 06/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

889 2ND ST
MACON GA
31201-6862
US

IV. Provider business mailing address

9140 CORSEA DEL FONTANA WAY
NAPLES FL
34109-4397
US

V. Phone/Fax

Practice location:
  • Phone: 478-254-9363
  • Fax: 478-254-9362
Mailing address:
  • Phone: 12395972010
  • Fax: 239-597-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

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