MEDICARE: VASCULAR ACCESS CENTERS OF ILLINOIS AT NORTH CENTER LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1750870945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VASCULAR ACCESS CENTERS OF ILLINOIS AT NORTH CENTER LLC

Provider Business Mailing Address
First Line	:	210 S DES PLAINES ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-5500
Country	:	US
Telephone Number	:	312-654-2721
Fax Number	:	866-954-5804

Provider Business Practice Location Address
First Line	:	2608 W ADDISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-5905
Country	:	US
Telephone Number	:	773-756-3333
Fax Number	:	773-549-1717

Authorized Official
Title or Position	:	CFO/VICE PRES FINANCE
Name	:	P. KEVIN FLYNN
Credential	:
Telephone Number	:	312-654-2711

Provider Enumeration Date	:	05/03/2018
Last Update Date	:	05/03/2018

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