Provider Demographics
NPI:1942981618
Name:PREMIER VASCULAR, LLC
Entity Type:Organization
Organization Name:PREMIER VASCULAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUDNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-895-0138
Mailing Address - Street 1:451 COLLEGE ST UNIT 13025
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-3009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:478-202-9505
Practice Address - Street 1:1902 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8132
Practice Address - Country:US
Practice Address - Phone:478-895-0138
Practice Address - Fax:478-202-9505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty