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General NPI Number Information
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NPI Number | 1194277210
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Entity Type | Organization
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Legal Business Name | SOUTHERN VASCULAR SPECIALISTS LLC
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Dates
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Enumeration Date | 10/25/2016
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Last Update Date | 10/25/2016
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Provider Practice Location Address
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Address Line | 505 GORDON AVE
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City | THOMASVILLE
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State | GA
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Zip | 31792-6645
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Country | US
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Telephone | 229-224-4858
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6010
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City | THOMASVILLE
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State | GA
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Zip | 31758-6010
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Country | US
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Telephone | 229-224-4858
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ALBERT ISAAC RICHARDSON II
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Credential | M.D.
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Telephone | 229-224-4858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 055328
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License Number State | GA
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