Provider Demographics
NPI:1407957871
Name:VASCULAR SPECIALIST OF VENICE AND SARASOTA PL
Entity Type:Organization
Organization Name:VASCULAR SPECIALIST OF VENICE AND SARASOTA PL
Other - Org Name:SARASOTA INTERVENTIONAL RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:GRUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-378-3231
Mailing Address - Street 1:600 N CATTLEMEN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-6422
Mailing Address - Country:US
Mailing Address - Phone:941-378-3231
Mailing Address - Fax:941-378-3253
Practice Address - Street 1:600 N. CATTLEMEN RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6410
Practice Address - Country:US
Practice Address - Phone:941-378-3231
Practice Address - Fax:941-378-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME639732085R0204X
FLME119376208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010369900Medicaid
FLDF6481OtherRR MEDICARE
FL002LXOtherBCBS FL
FLDF6481OtherRR MEDICARE
FL002LXOtherBCBS FL
FL=========OtherTAX ID