Healthcare Provider Details

I. General information

NPI: 1043406838
Provider Name (Legal Business Name): VEIN SPECIALISTS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 CORPORATE WAY STE A
JUPITER FL
33458-4359
US

IV. Provider business mailing address

5155 CORPORATE WAY STE A
JUPITER FL
33458-4359
US

V. Phone/Fax

Practice location:
  • Phone: 561-624-0123
  • Fax: 561-624-1453
Mailing address:
  • Phone: 561-624-0123
  • Fax: 561-624-1453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME 62477
License Number StateFL

VIII. Authorized Official

Name: DR. STEVEN M. TIDWELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 561-624-0123