Provider Demographics
NPI:1861439614
Name:THE VASCULAR CLINIC LLC
Entity Type:Organization
Organization Name:THE VASCULAR CLINIC LLC
Other - Org Name:VASCULAR CLINIC OF NORTHWEST GEORGIA, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SAAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-858-0204
Mailing Address - Street 1:102 GROSS CRESCENT CIR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3600
Mailing Address - Country:US
Mailing Address - Phone:706-858-0204
Mailing Address - Fax:706-858-0225
Practice Address - Street 1:102 GROSS CRESCENT CIR
Practice Address - Street 2:SUITE 204
Practice Address - City:FT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3600
Practice Address - Country:US
Practice Address - Phone:706-858-0204
Practice Address - Fax:706-858-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4176994OtherTENNESSE BLUE SHIELD
GA143447302AMedicaid
TN3734225Medicaid
GADE0292Medicare PIN
GA143447302AMedicaid
TNDG8472Medicare PIN
TN3734225Medicaid