MEDICARE: SIOUXLAND VEIN CENTER 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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	30608	IA

General Provider Information

NPI Number	:	1457687782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIOUXLAND VEIN CENTER PC

Provider Business Mailing Address
First Line	:	4630 SINGING HILLS BLVD
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-9702
Country	:	US
Telephone Number	:	712-271-8346
Fax Number	:	712-271-8347

Provider Business Practice Location Address
First Line	:	4630 SINGING HILLS BLVD
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-9702
Country	:	US
Telephone Number	:	712-271-8346
Fax Number	:	712-271-8347

Authorized Official
Title or Position	:	MD
Name	:	MARK WADE NIELSEN
Credential	:	MD
Telephone Number	:	712-271-8346

Provider Enumeration Date	:	10/21/2009
Last Update Date	:	10/21/2009

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