=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376654830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA VASCULAR CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 03/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5671 PEACHTREE DUNWOODY RD NE SUITE 250
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-256-0170
-----------------------------------------------------
Fax | 404-256-2998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5671 PEACHTREE DUNWOODY RD NE SUITE 250
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-256-0170
-----------------------------------------------------
Fax | 404-256-2998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BROOKS A WHITNEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-256-0170
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------