Provider Demographics
NPI:1881625200
Name:NORTHEAST PHILADELPHIA VASCULAR SURGEONS PC
Entity type:Organization
Organization Name:NORTHEAST PHILADELPHIA VASCULAR SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHITTUR
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-969-3944
Mailing Address - Street 1:2000 GRANT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4378
Mailing Address - Country:US
Mailing Address - Phone:215-969-3944
Mailing Address - Fax:215-969-3886
Practice Address - Street 1:2000 GRANT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4378
Practice Address - Country:US
Practice Address - Phone:215-969-3944
Practice Address - Fax:215-969-3886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011942860002Medicaid
PA0595939OtherAETNA
PA0000569420OtherBLUE SHIELD
PA0748057000OtherKHPE
PA569420Medicare ID - Type Unspecified