Healthcare Provider Details

I. General information

NPI: 1750135406
Provider Name (Legal Business Name): MVC GA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11660 ALPHARETTA HWY STE 515
ROSWELL GA
30076-3887
US

IV. Provider business mailing address

7125 ORCHARD LAKE RD STE 120
WEST BLOOMFIELD MI
48322-3627
US

V. Phone/Fax

Practice location:
  • Phone: 866-607-2308
  • Fax:
Mailing address:
  • Phone: 866-607-2308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MATT KIRK
Title or Position: CHIEF REVENUE OFFICER
Credential:
Phone: 708-710-9931