Healthcare Provider Details

I. General information

NPI: 1104626647
Provider Name (Legal Business Name): USA VEIN CLINICS OF MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9515 DEERECO RD STE 205C
LUTHERVILLE TIMONIUM MD
21093-2153
US

IV. Provider business mailing address

304 WAINWRIGHT DR
NORTHBROOK IL
60062-1900
US

V. Phone/Fax

Practice location:
  • Phone: 410-252-6836
  • Fax:
Mailing address:
  • Phone: 323-350-1204
  • Fax: 224-235-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY JACKSON
Title or Position: MANAGER
Credential:
Phone: 323-350-1204