1124225057 NPI number — VEIN SPECIALISTS OF NORTH CAROLINA, PA

Table of content: (NPI 1124225057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124225057 NPI number — VEIN SPECIALISTS OF NORTH CAROLINA, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VEIN SPECIALISTS OF NORTH CAROLINA, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124225057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2015 SPRING RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-3944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-725-2700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6752 ROCK SPRING ROAD
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-798-5347
Provider Business Practice Location Address Fax Number:
910-763-6570
Provider Enumeration Date:
07/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
630-725-2737

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC3861 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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