Provider Demographics
NPI:1073396453
Name:VASCULAR AND VEIN INSTITUTE OF THE SOUTH, PLLC
Entity Type:Organization
Organization Name:VASCULAR AND VEIN INSTITUTE OF THE SOUTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEONA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-641-9529
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33425-0386
Mailing Address - Country:US
Mailing Address - Phone:203-641-9529
Mailing Address - Fax:
Practice Address - Street 1:1653 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2511
Practice Address - Country:US
Practice Address - Phone:901-390-2930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VASCULAR AND VEIN INSTITUTE OF THE SOUTH PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty