MEDICARE: GEORGIA INTERVENTIONAL AND VASCULAR SPECIALISTS, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	042261	GA
2	208600000X	Surgery Physician
3	202K00000X	Phlebology Physician	042261	GA

General Provider Information

NPI Number	:	1255683470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA INTERVENTIONAL AND VASCULAR SPECIALISTS, PC

Provider Business Mailing Address
First Line	:	2015 SPRING RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-3944
Country	:	US
Telephone Number	:	630-725-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	264 19TH ST NW STE 2240
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30363-1139
Country	:	US
Telephone Number	:	404-532-1564
Fax Number	:	404-532-1565

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	CYNTHIA JONES
Credential	:
Telephone Number	:	630-725-2737

Provider Enumeration Date	:	10/11/2012
Last Update Date	:	02/08/2022

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