Basic Information
| Provider Information | |||||||||
| NPI: | 1922429141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA VASCULAR ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAFAYETTE REGIONAL VEIN & LASER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 ST FRANCIS WAY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658072770 | ||||||||
| FaxNumber: | 7658070348 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 ST FRANCIS WAY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658072770 | ||||||||
| FaxNumber: | 7658070348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2013 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHUL | ||||||||
| AuthorizedOfficialFirstName: | MARLIN | ||||||||
| AuthorizedOfficialMiddleName: | WADE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7658072770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD, MBA, RVT, FACPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 202K00000X | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Phlebology |
ID Information
| ID | Type | State | Issuer | Description | 11398636 | 01 | IN | CAQH | OTHER | 100379350 | 05 | IN | MEDICAID |