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General NPI Number Information
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NPI Number | 1700640802
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Entity Type | Organization
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Legal Business Name | ADVANCED VASCULAR INSTITUTE, LLC
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Dates
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Enumeration Date | 02/08/2024
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 2401 STATE AVE STE 100
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City | PANAMA CITY
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State | FL
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Zip | 32405-3942
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Country | US
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Telephone | 502-262-5980
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Fax |
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Provider Business Mailing Address
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Address Line | 2401 STATE AVE STE 100
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City | PANAMA CITY
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State | FL
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Zip | 32405-3942
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Country | US
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Telephone | 502-262-5980
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Fax |
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Authorized Official
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Title or Position | CMO
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Name | DR. AHMED ALY FARAG
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Credential | MD
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Telephone | 850-628-9177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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