Provider Demographics
NPI:1376930339
Name:GENESIS VASCULAR OF POOLER, LLC
Entity Type:Organization
Organization Name:GENESIS VASCULAR OF POOLER, LLC
Other - Org Name:GV OF POOLER
Other - Org Type:Other Name
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:856-335-5025
Mailing Address - Street 1:575 N ROUTE 73
Mailing Address - Street 2:STE A6
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-9289
Mailing Address - Country:US
Mailing Address - Phone:856-335-5025
Mailing Address - Fax:856-213-9269
Practice Address - Street 1:1000 TOWNE CENTER BLVD
Practice Address - Street 2:BUILDING 400
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4052
Practice Address - Country:US
Practice Address - Phone:912-662-0223
Practice Address - Fax:912-662-0224
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS GLOBAL HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-16
Last Update Date:2015-11-13
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