Provider Demographics
NPI:1588029672
Name:ADVANCED VEIN INSTITUTE OF ARIZONA, LLC
Entity Type:Organization
Organization Name:ADVANCED VEIN INSTITUTE OF ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:B
Authorized Official - Last Name:BABCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-454-5562
Mailing Address - Street 1:2155 E CONFERENCE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-2604
Mailing Address - Country:US
Mailing Address - Phone:480-454-5562
Mailing Address - Fax:480-868-2272
Practice Address - Street 1:2155 E CONFERENCE DR STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2604
Practice Address - Country:US
Practice Address - Phone:480-454-5562
Practice Address - Fax:480-868-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ177602085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104597Medicaid
AZE52286Medicare UPIN
AZQ46766Medicare UPIN
AZG47511Medicare UPIN
AZ104597Medicaid