Healthcare Provider Details

I. General information

NPI: 1063519296
Provider Name (Legal Business Name): SKIN VEIN & COSMETIC SURGERY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9130 COLUMBIA AVE SUITE A
MUNSTER IN
46321
US

IV. Provider business mailing address

9130 COLUMBIA AVE SUITE A
MUNSTER IN
46321
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-4343
  • Fax: 219-836-4387
Mailing address:
  • Phone: 219-836-4343
  • Fax: 219-836-4387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01029379A
License Number StateIN

VIII. Authorized Official

Name: AHMAD FATHI
Title or Position: PRESIDENT
Credential: MD
Phone: 219-836-4343