Provider Demographics
NPI:1861014383
Name:POLARIS VEIN CENTER
Entity Type:Organization
Organization Name:POLARIS VEIN CENTER
Other - Org Name:AMANDA S. COOPER
Other - Org Type:Other Name
Authorized Official - Title/Position:DOM
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-264-8970
Mailing Address - Street 1:8100 RAVINES EDGE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5426
Mailing Address - Country:US
Mailing Address - Phone:614-488-5090
Mailing Address - Fax:614-845-5216
Practice Address - Street 1:8100 RAVINES EDGE CT STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-5426
Practice Address - Country:US
Practice Address - Phone:614-488-5090
Practice Address - Fax:614-845-5216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2764101Medicaid