Healthcare Provider Details

I. General information

NPI: 1275123671
Provider Name (Legal Business Name): ONE SOURCE VASCULAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 HABERSHAM DR
WAYCROSS GA
31501-5306
US

IV. Provider business mailing address

501 W ONEIDA ST
WAYCROSS GA
31501-5337
US

V. Phone/Fax

Practice location:
  • Phone: 912-490-9420
  • Fax:
Mailing address:
  • Phone: 912-283-7596
  • Fax: 912-283-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID P MURPHY
Title or Position: MANAGER
Credential: DPM
Phone: 912-283-6471