Provider Demographics
NPI:1023154333
Name:MIDWEST VEIN TREATMENT CLINIC INC
Entity type:Organization
Organization Name:MIDWEST VEIN TREATMENT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-342-0455
Mailing Address - Street 1:8101 MILLER FARM LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-7320
Mailing Address - Country:US
Mailing Address - Phone:937-281-0200
Mailing Address - Fax:937-281-0203
Practice Address - Street 1:8101 MILLER FARM LN
Practice Address - Street 2:SUITE A
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-7320
Practice Address - Country:US
Practice Address - Phone:937-281-0200
Practice Address - Fax:937-281-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5556OtherRAILROAD MEDICARE GROUP
CA5556OtherRAILROAD MEDICARE GROUP
A15307Medicare UPIN