MEDICARE: GRAND VEIN SPECIALISTS 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	202K00000X	Phlebology Physician	036-116087	IL
2	207Q00000X	Family Medicine Physician	036-116087	IL

General Provider Information

NPI Number	:	1255603247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND VEIN SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	4952 W IRVING PARK RD STE 300
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2693
Country	:	US
Telephone Number	:	773-942-6141
Fax Number	:	866-707-2267

Provider Business Practice Location Address
First Line	:	4952 W IRVING PARK RD STE 300
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2693
Country	:	US
Telephone Number	:	773-942-6141
Fax Number	:	866-707-2267

Authorized Official
Title or Position	:	OWNER
Name	:	JAVIER FLORES
Credential	:
Telephone Number	:	773-942-6141

Provider Enumeration Date	:	02/06/2012
Last Update Date	:	02/09/2021

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Directions to “GRAND VEIN SPECIALISTS LLC ” Practice Location

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