Provider Demographics
NPI:1922429141
Name:INDIANA VASCULAR ASSOCIATES, LLC
Entity Type:Organization
Organization Name:INDIANA VASCULAR ASSOCIATES, LLC
Other - Org Name:LAFAYETTE REGIONAL VEIN & LASER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLIN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:SCHUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA, RVT, FACPH
Authorized Official - Phone:765-807-2770
Mailing Address - Street 1:3920 ST FRANCIS WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4917
Mailing Address - Country:US
Mailing Address - Phone:765-807-2770
Mailing Address - Fax:765-807-0348
Practice Address - Street 1:3920 ST FRANCIS WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4917
Practice Address - Country:US
Practice Address - Phone:765-807-2770
Practice Address - Fax:765-807-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11398636OtherCAQH
IN100379350Medicaid
IN11398636OtherCAQH
IN100379350Medicaid