Basic Information
Provider Information | |||||||||
NPI: | 1447658877 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTER FOR VEIN RESTORATION PA PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7474 GREENWAY CENTER DR | ||||||||
Address2: | STE 1000 | ||||||||
City: | GREENBELT | ||||||||
State: | MD | ||||||||
PostalCode: | 207703504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2409653206 | ||||||||
FaxNumber: | 2404734323 | ||||||||
Practice Location | |||||||||
Address1: | 1338 BRISTOL PIKE STE 205 | ||||||||
Address2: |   | ||||||||
City: | BENSALEM | ||||||||
State: | PA | ||||||||
PostalCode: | 190205679 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8558308346 | ||||||||
FaxNumber: | 2404734321 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2014 | ||||||||
LastUpdateDate: | 05/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER-FELDER | ||||||||
AuthorizedOfficialFirstName: | PAMELA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 2409653206 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.