Provider Demographics
NPI:1265521181
Name:WESTERN VASCULAR INSTITUTE PLLC
Entity type:Organization
Organization Name:WESTERN VASCULAR INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-668-5000
Mailing Address - Street 1:7165 E UNIVERSITY DR
Mailing Address - Street 2:SUITE 187
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-6400
Mailing Address - Country:US
Mailing Address - Phone:480-668-5000
Mailing Address - Fax:480-347-1000
Practice Address - Street 1:7165 E UNIVERSITY DR
Practice Address - Street 2:SUITE 183
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-6400
Practice Address - Country:US
Practice Address - Phone:480-668-5000
Practice Address - Fax:480-668-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103899Medicaid