Provider Demographics
NPI:1003140351
Name:CARDIOVASCULAR GROUP
Entity type:Organization
Organization Name:CARDIOVASCULAR GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:WOOD
Authorized Official - Last Name:THAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:478-457-7128
Mailing Address - Street 1:1051 STONE SHOALS CT
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-2774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:755 WALTHER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8725
Practice Address - Country:US
Practice Address - Phone:678-252-3707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty