Provider Demographics
NPI:1962508853
Name:INDIANA PHLEBOLOGY PC
Entity Type:Organization
Organization Name:INDIANA PHLEBOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMORUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-593-8460
Mailing Address - Street 1:PO BOX 451
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0451
Mailing Address - Country:US
Mailing Address - Phone:847-593-8460
Mailing Address - Fax:877-285-5883
Practice Address - Street 1:371 E 84TH DR STE 371
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6484
Practice Address - Country:US
Practice Address - Phone:219-736-7165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN202K00000X, 2085R0204X, 208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDO6229OtherMEDICARE RAILROAD
INDO6229OtherMEDICARE RAILROAD