Provider Demographics
NPI:1104076009
Name:ATLANTA VEIN CLINIC, LLC
Entity type:Organization
Organization Name:ATLANTA VEIN CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHALAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHADEVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-805-6167
Mailing Address - Street 1:4060 JOHNS CREEK PKWY
Mailing Address - Street 2:BUILDING E
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1230
Mailing Address - Country:US
Mailing Address - Phone:678-615-3511
Mailing Address - Fax:678-395-4642
Practice Address - Street 1:4060 JOHNS CREEK PKWY
Practice Address - Street 2:BUILDING E
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1230
Practice Address - Country:US
Practice Address - Phone:404-805-6167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059827261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1447463609OtherNPI
GA1447463609OtherNPI