=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508104068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GILVYDIS VEIN CLINIC, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2013
-----------------------------------------------------
Last Update Date | 08/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2127 MIDLANDS CT #102
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-981-4742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2127 MIDLANDS CT #102
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-981-4742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RIMVYDAS P. GILVYDIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-571-6770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------