Basic Information
| Provider Information | |||||||||
| NPI: | 1518563790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKNER VEIN AND AESTHETICS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1330 LIBERTY RD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217846412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409135900 | ||||||||
| FaxNumber: | 2409135901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 LIBERTY RD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217846412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409135900 | ||||||||
| FaxNumber: | 2409135901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2020 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUCKNER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2409135900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.