Provider Demographics
NPI:1225212137
Name:US VASCULAR ACCESS CENTER OF PHILADELPHIA, LLC
Entity Type:Organization
Organization Name:US VASCULAR ACCESS CENTER OF PHILADELPHIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR.MGR. REGULATORY/REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-661-5766
Mailing Address - Street 1:4220 MARKET ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3007
Mailing Address - Country:US
Mailing Address - Phone:215-386-4959
Mailing Address - Fax:
Practice Address - Street 1:4220 MARKET ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3007
Practice Address - Country:US
Practice Address - Phone:215-386-4959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA20461501291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA20461501OtherSTATE LICENSE