Provider Demographics
NPI:1578942512
Name:SOUTHERN VASCULAR ASSOCIATES LLC
Entity Type:Organization
Organization Name:SOUTHERN VASCULAR ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RACHEED
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GHANAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-356-1252
Mailing Address - Street 1:127 QUEENSBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5421
Mailing Address - Country:US
Mailing Address - Phone:337-356-1252
Mailing Address - Fax:
Practice Address - Street 1:127 QUEENSBERRY DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5421
Practice Address - Country:US
Practice Address - Phone:337-356-1252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2052142086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2315617Medicaid
LAP01174911Medicare PIN