MEDICARE: VEIN CARE OF OHIO-WEST, LLC

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	2085R0204X	Vascular & Interventional Radiology Physician	35053437	OH
2	208D00000X	General Practice Physician	35053437	OH

General Provider Information

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

Provider Business Mailing Address
First Line	:	4330 W 150TH ST
Second Line	:	SUITE 103
City	:	CLEVELAND
State	:	OH
Zip	:	44135-1362
Country	:	US
Telephone Number	:	216-688-8000
Fax Number	:	216-688-0075

Provider Business Practice Location Address
First Line	:	4330 W 150TH ST
Second Line	:	SUITE 103
City	:	CLEVELAND
State	:	OH
Zip	:	44135-1362
Country	:	US
Telephone Number	:	216-688-8000
Fax Number	:	216-688-0075

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRADLEY A BLACKBURN
Credential	:	M.D.
Telephone Number	:	216-688-8000

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	09/11/2025

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