Provider Demographics
NPI:1639443773
Name:PREMIER VASCULAR CARE PC
Entity Type:Organization
Organization Name:PREMIER VASCULAR CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AJITH
Authorized Official - Middle Name:
Authorized Official - Last Name:KADAKOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-573-8030
Mailing Address - Street 1:3205 LEGACY CT
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-3634
Mailing Address - Country:US
Mailing Address - Phone:583-573-8030
Mailing Address - Fax:
Practice Address - Street 1:1701 SOUTH BLVD E STE B75
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6122
Practice Address - Country:US
Practice Address - Phone:248-243-3935
Practice Address - Fax:248-284-7530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010932222086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315045037OtherCONTROLLED SUBSTANCE LICENSE
MI4301093222OtherLICENSE
MI1891742128OtherINDV NPI
MI1891742128OtherINDV NPI
MI4301093222OtherLICENSE