Provider Demographics
NPI:1578625349
Name:PENNSYLVANIA VASCULAR ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:PENNSYLVANIA VASCULAR ASSOCIATES, P.C.
Other - Org Name:PA VASCULAR ASSOC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-829-5093
Mailing Address - Street 1:700 SPRUCE STREET
Mailing Address - Street 2:STE 101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-0423
Mailing Address - Country:US
Mailing Address - Phone:215-829-5000
Mailing Address - Fax:215-627-0578
Practice Address - Street 1:700 SPRUCE STREET
Practice Address - Street 2:STE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-0423
Practice Address - Country:US
Practice Address - Phone:215-829-5000
Practice Address - Fax:215-627-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016875000001Medicaid
PACN5867OtherRAILROAD MEDICARE
NJ085130Medicare PIN
PACN5867OtherRAILROAD MEDICARE