Provider Demographics
NPI:1710938659
Name:REGIONAL VASCULAR & VEIN INSTITUTE, INC
Entity Type:Organization
Organization Name:REGIONAL VASCULAR & VEIN INSTITUTE, INC
Other - Org Name:REGIONAL SURGICAL SPECIALISTS, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PREM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-602-7702
Mailing Address - Street 1:400 MEDICAL PARK DR
Mailing Address - Street 2:STE 203
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-3207
Mailing Address - Country:US
Mailing Address - Phone:330-602-7702
Mailing Address - Fax:330-602-4169
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:STE 203
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-3207
Practice Address - Country:US
Practice Address - Phone:330-602-7702
Practice Address - Fax:330-602-4169
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGIONAL SURGICAL SPECIALISTS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-15
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071936208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCG7848OtherRR MEDICARE DOVER
OH2187360Medicaid
OH2300709Medicaid
OHID01191OtherCANTON LAB
OH2267676Medicaid
OHCK3919OtherRR MEDICARE CANTON
OH9301653Medicare PIN
OHCG7848OtherRR MEDICARE DOVER