MEDICARE: AVITAS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085R0204X	Vascular & Interventional Radiology Physician
2	208VP0014X	Interventional Pain Medicine Physician
3	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1043042054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVITAS LLC

Provider Business Mailing Address
First Line	:	PO BOX 894
Second Line	:
City	:	CAMBRIDGE
State	:	OH
Zip	:	43725-0894
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	172 S FRIENDSHIP DR STE A
Second Line	:
City	:	NEW CONCORD
State	:	OH
Zip	:	43762-9641
Country	:	US
Telephone Number	:	740-214-8998
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DENNIS EAGLEEYE
Credential	:
Telephone Number	:	740-214-8998

Provider Enumeration Date	:	08/19/2024
Last Update Date	:	08/19/2024

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Directions to “AVITAS LLC ” Practice Location

Language	Start Address	Practice Location

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