Basic Information
| Provider Information | |||||||||
| NPI: | 1174630545 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VEIN SPECIALISTS OF THE NORTH SHORE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 CUMMINGS CENTER | ||||||||
| Address2: | SUITE 110E | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789228346 | ||||||||
| FaxNumber: | 9789228345 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CUMMINGS CENTER | ||||||||
| Address2: | SUITE 110E | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789228346 | ||||||||
| FaxNumber: | 9789228345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 04/19/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | ALLAN | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9789228346 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9738631 | 05 | MA | MEDICAID | 110069857A | 05 | MA | MEDICAID |