1669577979 NPI number — MARYLAND VEIN PROFESSIONALS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669577979 NPI number — MARYLAND VEIN PROFESSIONALS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND VEIN PROFESSIONALS, LLC
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:
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:
1669577979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6030 MARSHALEE DR
Provider Second Line Business Mailing Address:
SUITE 311
Provider Business Mailing Address City Name:
ELKRIDGE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
400-964-8346
Provider Business Mailing Address Fax Number:
410-964-8350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8860 COLUMBIA 100 PKWY
Provider Second Line Business Practice Location Address:
SUITE 216
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21045-2195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-964-8346
Provider Business Practice Location Address Fax Number:
410-964-8350
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CALURE
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
410-964-8346

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  D0050590 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 784323200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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