Provider Demographics
NPI:1831503911
Name:ARTERY AND VEIN SPECIALISTS OF THE EMERALD COAST, INC.
Entity type:Organization
Organization Name:ARTERY AND VEIN SPECIALISTS OF THE EMERALD COAST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MANOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-398-2548
Mailing Address - Street 1:4615 NW 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-4809
Mailing Address - Country:US
Mailing Address - Phone:850-398-2548
Mailing Address - Fax:850-398-2548
Practice Address - Street 1:4615 NW 53RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-4809
Practice Address - Country:US
Practice Address - Phone:850-398-2548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD321272086S0129X
SCMD324872086S0129X
GA753092086S0129X
FLME1121232086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012102000Medicaid
AL161998Medicaid
FL012102000Medicaid
AL161998Medicaid
FLGM107XMedicare PIN