Provider Demographics
NPI:1437194909
Name:ADVANCED VEIN AND LASER CENTRE,LTD
Entity Type:Organization
Organization Name:ADVANCED VEIN AND LASER CENTRE,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROSENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-367-4040
Mailing Address - Street 1:1800 HOLLISTER DR
Mailing Address - Street 2:STE 121
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-367-4040
Mailing Address - Fax:847-367-4848
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:STE 121
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-367-4040
Practice Address - Fax:847-367-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932355OtherBLUE CROSS BLUE SHIELD
IL210031Medicare ID - Type Unspecified
ILE18583Medicare UPIN