Healthcare Provider Details

I. General information

NPI: 1710425913
Provider Name (Legal Business Name): FLOWOOD VASCULAR ACCESS ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAKELAND SQUARE EXT STE B
FLOWOOD MS
39232-7626
US

IV. Provider business mailing address

PO BOX 419663
BOSTON MA
02241-9663
US

V. Phone/Fax

Practice location:
  • Phone: 601-936-0890
  • Fax: 601-936-0891
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREGG MILLER
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 717-515-4048