Healthcare Provider Details

I. General information

NPI: 1427050046
Provider Name (Legal Business Name): DECATUR VEIN CLINIC, MICHIGAN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3152 PEREGRINE DR NE 100
GRAND RAPIDS MI
49525-9723
US

IV. Provider business mailing address

PO BOX 4237
CARMEL IN
46082-4237
US

V. Phone/Fax

Practice location:
  • Phone: 616-447-0707
  • Fax:
Mailing address:
  • Phone: 317-218-2800
  • Fax:

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: DAVID R DECATUR
Title or Position: CEO
Credential: MD
Phone: 317-218-2800