Provider Demographics
NPI:1861004780
Name:INNOVATIVE VASCULAR & VEIN OF ATLANTA
Entity Type:Organization
Organization Name:INNOVATIVE VASCULAR & VEIN OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-381-4666
Mailing Address - Street 1:3001 PALM HARBOR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1930
Mailing Address - Country:US
Mailing Address - Phone:727-474-0090
Mailing Address - Fax:727-474-0055
Practice Address - Street 1:1100 LAKE HEARN DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1523
Practice Address - Country:US
Practice Address - Phone:470-381-4666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty