Provider Demographics
NPI:1942553359
Name:NORTHEAST GEORGIA VASCULAR CENTER
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA VASCULAR CENTER
Other - Org Name:VASCULAR CLINICS OF NORTHEAST GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-535-1948
Mailing Address - Street 1:4763 SHIRLEY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5108
Mailing Address - Country:US
Mailing Address - Phone:770-535-1948
Mailing Address - Fax:770-535-1488
Practice Address - Street 1:4763 SHIRLEY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-5108
Practice Address - Country:US
Practice Address - Phone:770-535-1948
Practice Address - Fax:770-535-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA61114305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1942553359OtherNPI