Provider Demographics
NPI:1407824022
Name:NORTHERN ILLINOIS VEIN CLINIC, LLC
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS VEIN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STEFFEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-316-8346
Mailing Address - Street 1:PO BOX 4632
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-4632
Mailing Address - Country:US
Mailing Address - Phone:815-391-7285
Mailing Address - Fax:
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:SUITE 404
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2200
Practice Address - Country:US
Practice Address - Phone:815-316-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212207Medicare PIN