Provider Demographics
NPI:1457667784
Name:VEIN CLINIC PA
Entity Type:Organization
Organization Name:VEIN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMEER
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-934-3296
Mailing Address - Street 1:470 W 78TH ST
Mailing Address - Street 2:STE. 250
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4524
Mailing Address - Country:US
Mailing Address - Phone:952-934-3296
Mailing Address - Fax:952-906-1737
Practice Address - Street 1:16372 KENRICK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-3540
Practice Address - Country:US
Practice Address - Phone:952-892-1222
Practice Address - Fax:952-892-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC05399OtherMEDICARE PTAN