Provider Demographics
NPI:1821108382
Name:VASCULAR MEDICINE AND SURGERY SPECIALIST OF ATLANTA,L.L.C.
Entity Type:Organization
Organization Name:VASCULAR MEDICINE AND SURGERY SPECIALIST OF ATLANTA,L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-299-6488
Mailing Address - Street 1:2675 N DECATUR RD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-299-6488
Mailing Address - Fax:404-299-7522
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 410
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-299-6488
Practice Address - Fax:404-299-7522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3979Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER