Provider Demographics
NPI:1740503440
Name:SOUTHEAST REGIONAL CARDIAC AND VASCULAR INSTITUTE, LLC
Entity type:Organization
Organization Name:SOUTHEAST REGIONAL CARDIAC AND VASCULAR INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OSTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-537-5314
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-535-3500
Mailing Address - Fax:912-535-4498
Practice Address - Street 1:101 HARRIS INDUSTRIAL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8852
Practice Address - Country:US
Practice Address - Phone:912-535-3500
Practice Address - Fax:912-535-4498
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-09
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65260207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA489617065AMedicaid
GA489617065AMedicaid