Provider Demographics
NPI:1952003618
Name:THIRD COAST VASCULAR ASC LLC
Entity Type:Organization
Organization Name:THIRD COAST VASCULAR ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TAHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-577-0250
Mailing Address - Street 1:2500 W LAYTON AVE STE 40
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5420
Mailing Address - Country:US
Mailing Address - Phone:262-577-0250
Mailing Address - Fax:
Practice Address - Street 1:1441 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1989
Practice Address - Country:US
Practice Address - Phone:262-577-0250
Practice Address - Fax:262-577-0251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical