Provider Demographics
NPI:1790029015
Name:PIEDMONT CAROLINA VASCULAR SURGERY, LLC
Entity Type:Organization
Organization Name:PIEDMONT CAROLINA VASCULAR SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2902
Mailing Address - Street 1:1721 EBENEZER RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-4103
Mailing Address - Country:US
Mailing Address - Phone:803-985-4000
Mailing Address - Fax:803-985-4006
Practice Address - Street 1:1721 EBENEZER RD
Practice Address - Street 2:SUITE 115
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-4103
Practice Address - Country:US
Practice Address - Phone:803-985-4000
Practice Address - Fax:803-985-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C177Medicare PIN