Healthcare Provider Details

I. General information

NPI: 1043773161
Provider Name (Legal Business Name): EFFINGHAM VASCULAR CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 TOWNE PARK DR W STE 204
RINCON GA
31326-5183
US

IV. Provider business mailing address

459 HIGHWAY 119 SOUTH ATTN.: CREDENTIALING
SPRINGFIELD GA
31329
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-6771
  • Fax: 912-295-5605
Mailing address:
  • Phone: 912-754-0175
  • Fax: 912-754-2570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FRAN BAKER-WITT
Title or Position: CEO
Credential: RN, MBA, LNHA
Phone: 912-754-0160