Provider Demographics
NPI:1417951740
Name:GEORGIA HEART & VASCULAR CENTER PC
Entity Type:Organization
Organization Name:GEORGIA HEART & VASCULAR CENTER PC
Other - Org Name:GEORGIA HEART & VASCULAR CENTER, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-745-5476
Mailing Address - Street 1:PO BOX 4128
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4128
Mailing Address - Country:US
Mailing Address - Phone:478-745-5476
Mailing Address - Fax:478-314-1596
Practice Address - Street 1:360 HOSPITAL DR. BLDG. D.
Practice Address - Street 2:STE. 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3874
Practice Address - Country:US
Practice Address - Phone:478-745-5476
Practice Address - Fax:478-314-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016394207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4887OtherMEDICARE GROUP
GRP4887Medicare ID - Type Unspecified