Provider Demographics
NPI:1184850752
Name:VEIN & ESTHETIC CENTRE
Entity Type:Organization
Organization Name:VEIN & ESTHETIC CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CRITCHLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-651-1882
Mailing Address - Street 1:3065 WILLIAM ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6393
Mailing Address - Country:US
Mailing Address - Phone:573-651-1882
Mailing Address - Fax:573-334-5302
Practice Address - Street 1:10419 FLEMING RD
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-3391
Practice Address - Country:US
Practice Address - Phone:573-651-1882
Practice Address - Fax:573-334-5302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VEIN & ESTHETIC CENTRE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK53155Medicare PIN