Provider Demographics
NPI:1184002586
Name:GENESIS VASCULAR OF LEHIGH VALLEY, LLC
Entity Type:Organization
Organization Name:GENESIS VASCULAR OF LEHIGH VALLEY, LLC
Other - Org Name:GV OF LEHIGH VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:O'DARE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:215-630-4909
Mailing Address - Street 1:575 N ROUTE 73 STE A6
Mailing Address - Street 2:
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-2440
Mailing Address - Country:US
Mailing Address - Phone:856-335-5025
Mailing Address - Fax:856-213-9269
Practice Address - Street 1:2111 WASHINGTON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-3803
Practice Address - Country:US
Practice Address - Phone:484-544-4160
Practice Address - Fax:484-544-4188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS GLOBAL HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty