Provider Demographics
NPI:1831589803
Name:THORVASC PA
Entity type:Organization
Organization Name:THORVASC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:DESMOND
Authorized Official - Last Name:DEGRAFT-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-301-8283
Mailing Address - Street 1:400 CAPITAL CIR SE
Mailing Address - Street 2:STE 18148
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-3802
Mailing Address - Country:US
Mailing Address - Phone:850-792-4722
Mailing Address - Fax:
Practice Address - Street 1:2623 CENTENNIAL BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0585
Practice Address - Country:US
Practice Address - Phone:850-792-4722
Practice Address - Fax:850-792-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLID379AMedicare PIN