MEDICARE: USA VASCULAR CENTER OF CHANTILLY 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	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1255901450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	USA VASCULAR CENTER OF CHANTILLY LLC

Provider Business Mailing Address
First Line	:	PO BOX 971
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60065-0971
Country	:	US
Telephone Number	:	847-593-8460
Fax Number	:

Provider Business Practice Location Address
First Line	:	5860 COLUMBIA PIKE STE 105A
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22041-2047
Country	:	US
Telephone Number	:	847-593-8460
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	YAN KATSNELSON
Credential	:	MD
Telephone Number	:	847-593-8460

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	04/18/2022

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