Provider Demographics
NPI:1740396043
Name:SOMERSET VENOUS CENTER PC
Entity Type:Organization
Organization Name:SOMERSET VENOUS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:ENGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-816-6300
Mailing Address - Street 1:3290 W BIG BEAVER
Mailing Address - Street 2:SUITE 410
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-816-6300
Mailing Address - Fax:248-816-6335
Practice Address - Street 1:3290 W BIG BEAVER
Practice Address - Street 2:SUITE 410
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-816-6300
Practice Address - Fax:248-816-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0F32839OtherBCBS MI
0P23860Medicare ID - Type Unspecified