Organization
AVVSC LAWRENCEVILLE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMISH TILARA M.D. (PRESIDENT)
(678) 878-4555
Entity
Organization
Contact information
Practice address
600 PROFESSIONAL DR, SUITE 160B, LAWRENCEVILLE, GA 30046-7651
(678) 878-4555
(678) 878-4556
Mailing address
600 PROFESSIONAL DR., SUITE 160 B, LAWRENCEVILLE, GA 30046-8717
Taxonomy
Speciality
Code
Description
License number
State
2085R0204X
Vascular & Interventional Radiology Physician
—
—
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
261QM2500X
Medical Specialty Clinic/Center
—
—
261QR0200X
Radiology Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
11C0001456
—
GA
Enumeration date
05/02/2015
Last updated
06/30/2023
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