Provider Demographics
NPI:1184609372
Name:SOUTHEAST VASCULAR GROUP LP
Entity type:Organization
Organization Name:SOUTHEAST VASCULAR GROUP LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:YONEHIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-429-0102
Mailing Address - Street 1:PO BOX 30090
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1090
Mailing Address - Country:US
Mailing Address - Phone:850-429-0102
Mailing Address - Fax:850-429-0803
Practice Address - Street 1:4800 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2447
Practice Address - Country:US
Practice Address - Phone:850-429-0102
Practice Address - Fax:850-429-0830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35697208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0329OtherHEALTH FIRST NETWORK
FL266355400Medicaid
FLCK8716OtherMEDICARE RAILROAD
AL529931590Medicaid
AL529913680Medicaid
AL529929230Medicaid
AL529929230Medicaid