Healthcare Provider Details

I. General information

NPI: 1578942512
Provider Name (Legal Business Name): SOUTHERN VASCULAR ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 QUEENSBERRY DR
LAFAYETTE LA
70508-5421
US

IV. Provider business mailing address

127 QUEENSBERRY DR
LAFAYETTE LA
70508-5421
US

V. Phone/Fax

Practice location:
  • Phone: 337-356-1252
  • Fax:
Mailing address:
  • Phone: 337-356-1252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number205214
License Number StateLA

VIII. Authorized Official

Name: MR. RACHEED JOSEPH GHANAMI
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 337-356-1252