Provider Demographics
NPI:1932167269
Name:VASCULAR INSTITUTE OF GEORGIA, PC
Entity Type:Organization
Organization Name:VASCULAR INSTITUTE OF GEORGIA, PC
Other - Org Name:VASCULAR INSITUTE OF GEORIGA, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:MITTENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-256-0404
Mailing Address - Street 1:5669 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1786
Mailing Address - Country:US
Mailing Address - Phone:404-256-0404
Mailing Address - Fax:404-847-0423
Practice Address - Street 1:5669 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1786
Practice Address - Country:US
Practice Address - Phone:404-256-0404
Practice Address - Fax:404-847-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1033184767OtherJ. MARK RHEUDASIL
GA00216466HMedicaid
GA1861466955OtherMARK G. COAN
GA00460039EMedicaid
GA1376517300OtherALAN KOORNICK
GA1528028925OtherMICHAEL D. CLARK
GA00206005IMedicaid
GA1629038476OtherPETER H'DOUBLER JR.
GA1598739559OtherMARK MITTENTHAL
GA00460039EMedicaid
GA00216466HMedicaid
GA1598739559OtherMARK MITTENTHAL
GAD29152Medicare UPIN
GA77BBBHBMedicare ID - Type UnspecifiedALAN KOORNICK
GA77BBBJPMedicare ID - Type UnspecifiedMICHAEL D. CLARK
GA00206005IMedicaid
GAE10085Medicare UPIN
GA1376517300OtherALAN KOORNICK
GAD30261Medicare UPIN