Provider Demographics
NPI:1558382648
Name:ADVANCED VEIN IMAGING & THERAPY PC
Entity Type:Organization
Organization Name:ADVANCED VEIN IMAGING & THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:GADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-960-6486
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050
Mailing Address - Country:US
Mailing Address - Phone:516-767-1755
Mailing Address - Fax:516-767-1951
Practice Address - Street 1:2016 BRONXDALE AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462
Practice Address - Country:US
Practice Address - Phone:718-960-9086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWGW531Medicare ID - Type Unspecified