Healthcare Provider Details

I. General information

NPI: 1962046763
Provider Name (Legal Business Name): SOUTHPARK VASCULAR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 CHARLES H DIMMOCK PKWY STE 101
COLONIAL HEIGHTS VA
23834-2990
US

IV. Provider business mailing address

3001 PALM HARBOR BLVD STE A
PALM HARBOR FL
34683-1930
US

V. Phone/Fax

Practice location:
  • Phone: 804-520-1764
  • Fax: 866-781-3220
Mailing address:
  • Phone: 727-214-0462
  • Fax: 727-474-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JANET DEES
Title or Position: PRESIDENT
Credential:
Phone: 727-214-0462