Provider Demographics
NPI:1003094897
Name:REGIONAL VASCULAR & VEIN INSTITUTE
Entity Type:Organization
Organization Name:REGIONAL VASCULAR & VEIN INSTITUTE
Other - Org Name:REGIONAL SURGICAL SPECIALISTS, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PREM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-602-7702
Mailing Address - Street 1:6046 WHIPPLE AVE NW STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7616
Mailing Address - Country:US
Mailing Address - Phone:330-588-8900
Mailing Address - Fax:330-588-8990
Practice Address - Street 1:6046 WHIPPLE AVE NW STE 203
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7616
Practice Address - Country:US
Practice Address - Phone:330-588-8900
Practice Address - Fax:330-588-8990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2267676Medicaid