Provider Demographics
NPI:1124051735
Name:VEIN CENTERS OF NORTHWEST IN
Entity type:Organization
Organization Name:VEIN CENTERS OF NORTHWEST IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATEO
Authorized Official - Middle Name:V
Authorized Official - Last Name:GUANZON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-2022
Mailing Address - Street 1:9201 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2807
Mailing Address - Country:US
Mailing Address - Phone:219-836-2022
Mailing Address - Fax:
Practice Address - Street 1:9305 CALUMET AVE
Practice Address - Street 2:SUITE E-2
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2887
Practice Address - Country:US
Practice Address - Phone:219-836-1555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035781A2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN214140Medicare ID - Type Unspecified