Healthcare Provider Details

I. General information

NPI: 1104076009
Provider Name (Legal Business Name): ATLANTA VEIN CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 JOHNS CREEK PKWY BUILDING E
SUWANEE GA
30024-1230
US

IV. Provider business mailing address

4060 JOHNS CREEK PKWY BUILDING E
SUWANEE GA
30024-1230
US

V. Phone/Fax

Practice location:
  • Phone: 404-805-6167
  • Fax:
Mailing address:
  • Phone: 678-615-3511
  • Fax: 678-395-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number059827
License Number StateGA

VIII. Authorized Official

Name: CHALAM MAHADEVAN
Title or Position: OWNER
Credential: MD
Phone: 404-805-6167