Basic Information
| Provider Information | |||||||||
| NPI: | 1396799110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILAGRO VEIN SOLUTIONS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 13385 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852673385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806099300 | ||||||||
| FaxNumber: | 4806099350 | ||||||||
| Practice Location | |||||||||
| Address1: | 490B W ZIA ROAD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059958346 | ||||||||
| FaxNumber: | 5059958345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5059958346 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.