Provider Demographics
NPI:1720388267
Name:CENTER FOR VEIN RESTORATION MI PLLC
Entity Type:Organization
Organization Name:CENTER FOR VEIN RESTORATION MI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:PLEFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-860-0003
Mailing Address - Street 1:12200 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9182
Mailing Address - Country:US
Mailing Address - Phone:301-860-0930
Mailing Address - Fax:
Practice Address - Street 1:15255 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2487
Practice Address - Country:US
Practice Address - Phone:855-830-8346
Practice Address - Fax:240-473-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053733208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty