Healthcare Provider Details

I. General information

NPI: 1104994219
Provider Name (Legal Business Name): VEIN CARE OF OHIO-WEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 W 150TH ST SUITE 103
CLEVELAND OH
44135-1362
US

IV. Provider business mailing address

4330 W 150TH ST SUITE 103
CLEVELAND OH
44135-1362
US

V. Phone/Fax

Practice location:
  • Phone: 216-688-8000
  • Fax: 216-688-0075
Mailing address:
  • Phone: 216-688-8000
  • Fax: 216-688-0075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35053437
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35053437
License Number StateOH

VIII. Authorized Official

Name: DR. BRADLEY A BLACKBURN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-688-8000