Basic Information
| Provider Information | |||||||||
| NPI: | 1649405200 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC VEIN CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3929 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600503151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157592368 | ||||||||
| FaxNumber: | 8157592367 | ||||||||
| Practice Location | |||||||||
| Address1: | 3929 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600503151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157592368 | ||||||||
| FaxNumber: | 8157592367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2009 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | CONTI | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | LEAD PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8157590800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.