=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184002586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS VASCULAR OF LEHIGH VALLEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2015
-----------------------------------------------------
Last Update Date | 05/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2111 WASHINGTON BLVD STE 1
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18042-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-544-4160
-----------------------------------------------------
Fax | 484-544-4188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 N ROUTE 73 STE A6
-----------------------------------------------------
City | WEST BERLIN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08091-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-335-5025
-----------------------------------------------------
Fax | 856-213-9269
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | JAMES THOMAS O'DARE III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-630-4909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------