Provider Demographics
NPI:1376863977
Name:ST. JOHNS VEIN CENTER, INC.
Entity Type:Organization
Organization Name:ST. JOHNS VEIN CENTER, INC.
Other - Org Name:ANCIENT CITY VEIN & VASCULAR, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-402-8346
Mailing Address - Street 1:8767 PERIMETER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5479
Mailing Address - Country:US
Mailing Address - Phone:904-402-8346
Mailing Address - Fax:904-402-8347
Practice Address - Street 1:8767 PERIMETER PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5479
Practice Address - Country:US
Practice Address - Phone:904-402-8346
Practice Address - Fax:904-402-8347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88184202K00000X
2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO535AMedicare UPIN