MEDICARE: DECATUR VEIN CLINIC, MICHIGAN, PC

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	:	1427050046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DECATUR VEIN CLINIC, MICHIGAN, PC

Provider Business Mailing Address
First Line	:	PO BOX 4237
Second Line	:
City	:	CARMEL
State	:	IN
Zip	:	46082-4237
Country	:	US
Telephone Number	:	317-218-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	3152 PEREGRINE DR NE
Second Line	:	100
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9723
Country	:	US
Telephone Number	:	616-447-0707
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DAVID R DECATUR
Credential	:	MD
Telephone Number	:	317-218-2800

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	08/22/2020

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