Provider Demographics
NPI:1063903078
Name:SOUTH ATLANTA VASCULAR INSTITUTE, LLC
Entity type:Organization
Organization Name:SOUTH ATLANTA VASCULAR INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-405-8496
Mailing Address - Street 1:4714 OAKLEIGH MANOR DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-4923
Mailing Address - Country:US
Mailing Address - Phone:770-688-5334
Mailing Address - Fax:
Practice Address - Street 1:4714 OAKLEIGH MANOR DR
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-4923
Practice Address - Country:US
Practice Address - Phone:770-688-5334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA705192085R0204X
GA668552086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1598965006Medicaid
MA1760644355Medicaid
TN1386869535Medicaid