Healthcare Provider Details

I. General information

NPI: 1851620249
Provider Name (Legal Business Name): VASCULAR ACCESS CENTER OF BOLIVAR COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E SUNFLOWER RD SUITE 100B
CLEVELAND MS
38732-2800
US

IV. Provider business mailing address

285 WILMINGTON W CHESTER PIKE
CHADDS FORD PA
19317-9039
US

V. Phone/Fax

Practice location:
  • Phone: 662-579-3484
  • Fax: 662-579-3485
Mailing address:
  • Phone: 610-558-2800
  • Fax: 610-558-4839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. RAE CREWS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 662-579-3484