Provider Demographics
NPI:1194277210
Name:SOUTHERN VASCULAR SPECIALISTS LLC
Entity type:Organization
Organization Name:SOUTHERN VASCULAR SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:229-224-4858
Mailing Address - Street 1:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31758-6010
Mailing Address - Country:US
Mailing Address - Phone:229-224-4858
Mailing Address - Fax:
Practice Address - Street 1:505 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6645
Practice Address - Country:US
Practice Address - Phone:229-224-4858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0553282086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty