Provider Demographics
NPI:1487772349
Name:CENTER FOR VEIN RESTORATION MD LLC
Entity type:Organization
Organization Name:CENTER FOR VEIN RESTORATION MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-965-3271
Mailing Address - Street 1:7474 GREENWAY CENTER DR
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3504
Mailing Address - Country:US
Mailing Address - Phone:240-965-3271
Mailing Address - Fax:240-473-4326
Practice Address - Street 1:7300 HANOVER DR
Practice Address - Street 2:SUITE 303
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2202
Practice Address - Country:US
Practice Address - Phone:240-965-3271
Practice Address - Fax:240-473-4326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD169600900Medicaid
MD169600900Medicaid
DCG00397Medicare ID - Type Unspecified