MEDICARE: VR PHYSICIAN FOR VEIN RESTORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician

General Provider Information

NPI Number	:	1063373009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VR PHYSICIAN FOR VEIN RESTORATION

Provider Business Mailing Address
First Line	:	7474 GREENWAY CENTER DR STE 1000
Second Line	:
City	:	GREENBELT
State	:	MD
Zip	:	20770-3500
Country	:	US
Telephone Number	:	240-965-3261
Fax Number	:

Provider Business Practice Location Address
First Line	:	1749 GRAND CONCOURSE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-8241
Country	:	US
Telephone Number	:	855-830-8346
Fax Number	:

Authorized Official
Title or Position	:	CRED MANAGER
Name	:	LORENA THOMAS
Credential	:
Telephone Number	:	815-254-1761

Provider Enumeration Date	:	11/19/2025
Last Update Date	:	11/19/2025

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