Provider Demographics
NPI:1518386184
Name:SOUTHEAST HEART AND VASCULAR
Entity Type:Organization
Organization Name:SOUTHEAST HEART AND VASCULAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOBUSHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHMUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-850-2698
Mailing Address - Street 1:1057 WEST AVE SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-5243
Mailing Address - Country:US
Mailing Address - Phone:215-850-2698
Mailing Address - Fax:
Practice Address - Street 1:1000 IRIS DR SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6632
Practice Address - Country:US
Practice Address - Phone:215-850-2698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066213207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty