Provider Demographics
NPI:1063652873
Name:INNOVAMED VEINS SC
Entity Type:Organization
Organization Name:INNOVAMED VEINS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-987-1802
Mailing Address - Street 1:2601 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3110
Mailing Address - Country:US
Mailing Address - Phone:815-987-1802
Mailing Address - Fax:815-987-1806
Practice Address - Street 1:2601 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3110
Practice Address - Country:US
Practice Address - Phone:815-987-1802
Practice Address - Fax:815-987-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074111202K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074111Medicaid
ILD16246Medicare UPIN
ILK06351Medicare PIN