Provider Demographics
NPI:1902864291
Name:COMPREHENSIVE VASCULAR SURGERY OF GEORGIA
Entity Type:Organization
Organization Name:COMPREHENSIVE VASCULAR SURGERY OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:PEARL
Authorized Official - Middle Name:E
Authorized Official - Last Name:ASCHE CROWE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:770-474-3882
Mailing Address - Street 1:150 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7344
Mailing Address - Country:US
Mailing Address - Phone:770-474-3882
Mailing Address - Fax:770-474-9392
Practice Address - Street 1:150 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7344
Practice Address - Country:US
Practice Address - Phone:770-474-3882
Practice Address - Fax:770-474-9392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2637032086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030828AMedicaid
GAGRP3147Medicare ID - Type UnspecifiedMEDICARE GROUP ID