Provider Demographics
NPI:1558442442
Name:SOUTHWEST VEIN CLINIC
Entity Type:Organization
Organization Name:SOUTHWEST VEIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:UMESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-726-7200
Mailing Address - Street 1:1300 COPPERFIELD AVE
Mailing Address - Street 2:SUITE 3070
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-2004
Mailing Address - Country:US
Mailing Address - Phone:815-726-7200
Mailing Address - Fax:815-722-8455
Practice Address - Street 1:1300 COPPERFIELD AVE
Practice Address - Street 2:SUITE 3070
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-2004
Practice Address - Country:US
Practice Address - Phone:815-726-7200
Practice Address - Fax:815-722-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL904940Medicare ID - Type Unspecified
ILC42050Medicare UPIN