Provider Demographics
NPI:1427435007
Name:AVVSC LAWRENCEVILLE, LLC
Entity type:Organization
Organization Name:AVVSC LAWRENCEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMISH
Authorized Official - Middle Name:
Authorized Official - Last Name:TILARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-878-4555
Mailing Address - Street 1:600 PROFESSIONAL DR.
Mailing Address - Street 2:SUITE 160 B
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 PROFESSIONAL DR
Practice Address - Street 2:SUITE 160B
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7651
Practice Address - Country:US
Practice Address - Phone:678-878-4555
Practice Address - Fax:678-878-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-02
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11C0001456Medicaid