Provider Demographics
NPI:1811184435
Name:MIDWEST VASCULAR INSTITUTE OF ILLINOIS
Entity type:Organization
Organization Name:MIDWEST VASCULAR INSTITUTE OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTARJEME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-963-0660
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-0297
Mailing Address - Country:US
Mailing Address - Phone:630-963-0660
Mailing Address - Fax:630-963-8348
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-963-0660
Practice Address - Fax:630-963-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036041533174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041533Medicaid
IL459981Medicare PIN
IL036041533Medicaid