Provider Demographics
NPI:1174074538
Name:MIVC ASC, LLC
Entity type:Organization
Organization Name:MIVC ASC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/VASCULAR SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:JARWRI
Authorized Official - Last Name:DORMU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-497-1590
Mailing Address - Street 1:8730 CHERRY LN
Mailing Address - Street 2:SUITE 10
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6212
Mailing Address - Country:US
Mailing Address - Phone:301-497-1590
Mailing Address - Fax:
Practice Address - Street 1:9201 CHERRY LANE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:301-497-1590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINIMALLY INVASIVE VASCULAR CENTER OF MARYLAND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-20
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical