Provider Demographics
NPI:1114912698
Name:FORTUNE VEIN CLINIC
Entity Type:Organization
Organization Name:FORTUNE VEIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:FORTUNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-991-2100
Mailing Address - Street 1:7125 E LINCOLN DR
Mailing Address - Street 2:SUITE B109
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-4429
Mailing Address - Country:US
Mailing Address - Phone:480-991-2100
Mailing Address - Fax:480-991-2102
Practice Address - Street 1:7125 E LINCOLN DR
Practice Address - Street 2:SUITE B109
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85253-4429
Practice Address - Country:US
Practice Address - Phone:480-991-2100
Practice Address - Fax:480-991-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ135402086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105643Medicare ID - Type UnspecifiedGROUP NUMBER
AZ105644Medicare ID - Type Unspecified105644
AZE39136Medicare UPIN