Healthcare Provider Details

I. General information

NPI: 1386291664
Provider Name (Legal Business Name): INNOVATIVE VASCULAR AND THERAPEUTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N HARLEM AVE STE 100
OAK PARK IL
60302-1205
US

IV. Provider business mailing address

PO BOX 379
PASADENA CA
91102-0379
US

V. Phone/Fax

Practice location:
  • Phone: 401-575-0308
  • Fax: 562-548-7540
Mailing address:
  • Phone: 401-575-0308
  • Fax: 562-548-7540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MALWINDER SINGH SINGHA
Title or Position: PRESIDENT
Credential: MD
Phone: 401-575-0308