Basic Information
Provider Information | |||||||||
NPI: | 1912906371 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER VEIN CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 520 E 22ND ST | ||||||||
Address2: |   | ||||||||
City: | LOMBARD | ||||||||
State: | IL | ||||||||
PostalCode: | 601486110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6308742542 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1051 W RAND RD | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 600042315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476181000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2005 | ||||||||
LastUpdateDate: | 07/16/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OBLONSKY | ||||||||
AuthorizedOfficialFirstName: | EVAN | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
AuthorizedOfficialTelephone: | 8476181000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.