Provider Demographics
NPI:1811937402
Name:VCP SOUTH, LLC
Entity type:Organization
Organization Name:VCP SOUTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-854-3333
Mailing Address - Street 1:4350 TOWNE CENTRE DR
Mailing Address - Street 2:STE 2000
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3301
Mailing Address - Country:US
Mailing Address - Phone:706-854-3333
Mailing Address - Fax:706-396-0615
Practice Address - Street 1:4350 TOWNE CENTRE DR
Practice Address - Street 2:STE 2000
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3301
Practice Address - Country:US
Practice Address - Phone:706-854-3333
Practice Address - Fax:706-396-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0485662086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA985661OtherBCBS
GA985661OtherBCBS
GAGRP6892Medicare ID - Type Unspecified