Basic Information
| Provider Information | |||||||||
| NPI: | 1881604783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VASCULAR DIAGNOSTIC AND TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 BURNET AVE | ||||||||
| Address2: | 1 RIDGEWAY | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135859009 | ||||||||
| FaxNumber: | 5135859373 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 OFFICE PARK DR | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450131496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138441000 | ||||||||
| FaxNumber: | 5138963727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROLF | ||||||||
| AuthorizedOfficialFirstName: | VERNON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5138441000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2451029 | 05 | OH | MEDICAID |