Provider Demographics
NPI:1487176004
Name:MODERN VASCULAR AND VEIN CENTER LLC
Entity type:Organization
Organization Name:MODERN VASCULAR AND VEIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLEWALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-334-0336
Mailing Address - Street 1:244 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-3813
Mailing Address - Country:US
Mailing Address - Phone:219-208-6218
Mailing Address - Fax:219-359-3679
Practice Address - Street 1:8127 MERRILLVILLE RD STE 1
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6306
Practice Address - Country:US
Practice Address - Phone:219-208-6218
Practice Address - Fax:475-275-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty