=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265658991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VEIN CENTER OF NORTHWEST INDIANA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 E 80TH PL SUITE 308 SOUTH TOWER
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-736-8118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1608 LINCOLNWAY
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-5856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-476-0352
-----------------------------------------------------
Fax | 219-531-0859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. AMJAD ALKADRI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 219-736-8118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------