Provider Demographics
NPI:1649468364
Name:SOUTH BEND VEIN CENTER FOR EXCELLLENCE, LLC
Entity type:Organization
Organization Name:SOUTH BEND VEIN CENTER FOR EXCELLLENCE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:OREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-232-5831
Mailing Address - Street 1:2025 EDISON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-5599
Mailing Address - Country:US
Mailing Address - Phone:574-232-5831
Mailing Address - Fax:574-968-0120
Practice Address - Street 1:2025 EDISON RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-5599
Practice Address - Country:US
Practice Address - Phone:574-232-5831
Practice Address - Fax:574-968-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030418A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC24537Medicare UPIN