Provider Demographics
NPI:1063519296
Name:SKIN VEIN & COSMETIC SURGERY CLINIC PC
Entity type:Organization
Organization Name:SKIN VEIN & COSMETIC SURGERY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FATHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-4343
Mailing Address - Street 1:9130 COLUMBIA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-836-4343
Mailing Address - Fax:219-836-4387
Practice Address - Street 1:9130 COLUMBIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-836-4343
Practice Address - Fax:219-836-4387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029379A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty