Provider Demographics
NPI:1255492203
Name:MIDWEST VASCULAR & VARICOSE VEIN CENTER LLC
Entity Type:Organization
Organization Name:MIDWEST VASCULAR & VARICOSE VEIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:INNOCENT
Authorized Official - Middle Name:N
Authorized Official - Last Name:UBUNAMA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:419-866-2000
Mailing Address - Street 1:7100 ORCHARD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528
Mailing Address - Country:US
Mailing Address - Phone:419-866-2000
Mailing Address - Fax:419-866-2010
Practice Address - Street 1:7100 ORCHARD CENTER DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528
Practice Address - Country:US
Practice Address - Phone:419-866-2000
Practice Address - Fax:419-866-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2945826Medicaid
OH2473783Medicaid
OHI06204Medicare UPIN
OH2473783Medicaid