=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982035242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEXGEN ARTERY & VEIN INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2013
-----------------------------------------------------
Last Update Date | 03/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28089 VANDERBILT DR SUITE 201
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-7521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-376-2967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28089 VANDERBILT DR SUITE 201
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-7521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-376-2967
-----------------------------------------------------
Fax | 239-405-8544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | PAULA SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 914-376-2967
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------