Provider Demographics
NPI:1346369287
Name:VASCULAR CENTER & VEIN CLINIC OF SOUTHERN INDIANA
Entity Type:Organization
Organization Name:VASCULAR CENTER & VEIN CLINIC OF SOUTHERN INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-336-6008
Mailing Address - Street 1:815 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2212
Mailing Address - Country:US
Mailing Address - Phone:812-336-6008
Mailing Address - Fax:812-339-6947
Practice Address - Street 1:815 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2212
Practice Address - Country:US
Practice Address - Phone:812-336-4947
Practice Address - Fax:812-339-6947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062063A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDF9011OtherMEDICARE RAILROAD GROUP
IN250940OtherMEDICARE GROUP
IN250940AOtherMEDICARE INDIVIDUAL
IN517966OtherANTHEM
IN200818170AOtherMEDICAID INDIVIDUAL
INP00400660OtherMEDICARE RAILROAD INDIVIDUAL
IN200818170OtherMEDICAID GROUP
INDF9011OtherMEDICARE RAILROAD GROUP