Advanced Vascular and Vein Associates, LLC
Organization Active NPI Multi-Specialty Clinic/Center · Flowood, MS
NPI 1275205809 · NPPES record last updated Oct 23, 2024
Key facts
- NPI
- 1275205809
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Multi-Specialty Clinic/Center 261QM1300X
- Legal business name
- ADVANCED VASCULAR AND VEIN ASSOCIATES, LLC
- Practice address
- 4436 Mangum Dr
Flowood, MS 39232-2113 - Phone
- (601) 586-7070
- Fax
- (601) 586-7071
- NPI assigned
- Oct 1, 2021
- Organization subpart
- No
Authorized official
- Name
- Lachelle Griffin
- Title
- Credentialing Manager
- Phone
- (769) 208-4437
Practitioners 12
-
Carli Crapps, NP
-
Kelsi Feduccia, NP
-
Justin Dale Manley, M.D.
-
Abdul G Bahro, MD
-
Grace Fairley Hampton, MSN,APRN,FNP-C,CPN
-
Rishi Ashok Roy, M.D.
-
Rachel M Sellers, PA-C
-
Heather Hammons, PA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D2250603 | Advanced Vascular & Vein Associates LLC | Certificate of waiver | Jan 26, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20211220000638 | MS | Part B Supplier - Clinic/Group Practice | 2668863085 |
Receives reassigned benefits from 12 practitioners Practice locations: Flowood, MS; Southaven, MS |
National Provider Directory
Locations
4436 Mangum Dr
Flowood, MS 39232
Phone (601) 586-7070
4436 Mangum Dr
Ste A
Flowood, MS 39232
Phone (601) 932-7363
60 Physicians Ln
#1
Southaven, MS 38671
Phone (662) 349-0707
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Vascular Surgery Physician |
2086S0129X | |||
| Multi-Specialty Clinic/Center | 261QM1300X | Yes |
Addresses
Primary practice location
4436 Mangum Dr
Flowood, MS 39232-2113
Mailing address
4436 Mangum Dr
Flowood, MS 39232-2113
Other providers in Flowood, MS
- Michael Adam Adcock
- Leslie Brannon Aden
- Adl Solutions
- Advance Medical Supplies, Inc.
- Advanced Foot Clinic PLLC
- Affordable Transportation Service LLC
- Agilitas USA, Inc
- Robyn Agnew
- Mohit Ahuja
- Jenna Marie Ainsworth
All providers in Flowood, MS · Multi-Specialty Clinic/Center in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 23, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.