MEDICARE: VEIN CLINIC PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C05399	OTHER	MN	MEDICARE PTAN

General Provider Information

NPI Number	:	1457667784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VEIN CLINIC PA

Provider Business Mailing Address
First Line	:	470 W 78TH ST
Second Line	:	STE. 250
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-4524
Country	:	US
Telephone Number	:	952-934-3296
Fax Number	:	952-906-1737

Provider Business Practice Location Address
First Line	:	16372 KENRICK AVE
Second Line	:	SUITE 100
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-3540
Country	:	US
Telephone Number	:	952-892-1222
Fax Number	:	952-892-1221

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DR. SAMEER GUPTA
Credential	:	MD
Telephone Number	:	952-934-3296

Provider Enumeration Date	:	08/24/2010
Last Update Date	:	01/02/2013

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Directions to “VEIN CLINIC PA ” Practice Location

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