Provider Demographics
NPI:1174753875
Name:VARICOSE VEIN MEDICAL OFFICE PC
Entity type:Organization
Organization Name:VARICOSE VEIN MEDICAL OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-331-0500
Mailing Address - Street 1:405 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1868
Mailing Address - Country:US
Mailing Address - Phone:631-474-1414
Mailing Address - Fax:
Practice Address - Street 1:405 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1868
Practice Address - Country:US
Practice Address - Phone:631-474-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17481001202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty