Basic Information
| Provider Information | |||||||||
| NPI: | 1720388267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR VEIN RESTORATION MI PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12200 ANNAPOLIS RD | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | GLENN DALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207699182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018600930 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15255 NORTHLINE RD | ||||||||
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| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
| FaxNumber: | 2404734321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2010 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | PLEFFNER | ||||||||
| AuthorizedOfficialFirstName: | OLGA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3018600003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | D0053733 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208600000X | D0053733 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.