Healthcare Provider Details

I. General information

NPI: 1962765081
Provider Name (Legal Business Name): GOATEE VASCULAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4036 RIVER OAKS DR UNIT B2
MYRTLE BEACH SC
29579-6695
US

IV. Provider business mailing address

1415 EASTRIDGE RD
RICHMOND VA
23229-5501
US

V. Phone/Fax

Practice location:
  • Phone: 757-333-2066
  • Fax: 757-467-2703
Mailing address:
  • Phone: 757-333-2066
  • Fax: 757-467-2703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateSC

VIII. Authorized Official

Name: MS. ANGELA N SCHWARZKOPF
Title or Position: ADMINISTRATOR
Credential: CPC, CMPE, MBA
Phone: 757-333-2066