Provider Demographics
NPI:1417381781
Name:MACON VASCULAR CARE, LLC
Entity type:Organization
Organization Name:MACON VASCULAR CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCNAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-597-2010
Mailing Address - Street 1:9140 CORSEA DEL FONTANA WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-4397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:889 2ND ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6862
Practice Address - Country:US
Practice Address - Phone:478-254-9363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty