Provider Demographics
NPI:1508360181
Name:NEPHROLOGY VASCULAR LAB OF CENTRAL ALABAMA ASC LLC
Entity Type:Organization
Organization Name:NEPHROLOGY VASCULAR LAB OF CENTRAL ALABAMA ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-644-8900
Mailing Address - Street 1:PO BOX 412142
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2142
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:484-924-0053
Practice Address - Street 1:1280 COLUMBIANA RD STE 120
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-1642
Practice Address - Country:US
Practice Address - Phone:205-916-5201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical