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General NPI Number Information
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NPI Number | 1619036928
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Entity Type | Organization
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Legal Business Name | GEORIA VASCULAR SURGERY PC
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1718 PEACHTREE ST NW SUITE 260
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City | ATLANTA
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State | GA
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Zip | 30309-2452
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Country | US
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Telephone | 404-350-9505
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Fax | 404-350-1611
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Provider Business Mailing Address
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Address Line | PO BOX 54157
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City | ATLANTA
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State | GA
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Zip | 30308-0157
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Country | US
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Telephone | 404-350-9505
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Fax | 404-350-1611
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Authorized Official
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Title or Position | EXECUTIVE ADMINISTRATOR
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Name | MRS. LAVERNE W POINDEXTER
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Credential | RN, MBA
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Telephone | 770-270-5229
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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 | 029071
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License Number State | GA
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