Healthcare Provider Details

I. General information

NPI: 1487176004
Provider Name (Legal Business Name): MODERN VASCULAR AND VEIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8127 MERRILLVILLE RD STE 1
MERRILLVILLE IN
46410-6306
US

IV. Provider business mailing address

244 W CENTRAL AVE
LOMBARD IL
60148-3813
US

V. Phone/Fax

Practice location:
  • Phone: 219-208-6218
  • Fax: 475-275-8031
Mailing address:
  • Phone: 219-208-6218
  • Fax: 219-359-3679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: NAZAR GOLEWALE
Title or Position: OWNER
Credential: MD
Phone: 574-334-0336