Provider Demographics
NPI:1255683470
Name:GEORGIA INTERVENTIONAL AND VASCULAR SPECIALISTS, PC
Entity Type:Organization
Organization Name:GEORGIA INTERVENTIONAL AND VASCULAR SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-725-2737
Mailing Address - Street 1:2015 SPRING RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-3944
Mailing Address - Country:US
Mailing Address - Phone:630-725-2700
Mailing Address - Fax:
Practice Address - Street 1:264 19TH ST NW STE 2240
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30363-1139
Practice Address - Country:US
Practice Address - Phone:404-532-1564
Practice Address - Fax:404-532-1565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042261202K00000X, 207R00000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G705744Medicare PIN