MEDICARE: VEIN CENTER AND MEDICAL SPA

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5281088	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1740358209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VEIN CENTER AND MEDICAL SPA

Provider Business Mailing Address
First Line	:	4020 COPPER VW
Second Line	:	SUITE 212
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7098
Country	:	US
Telephone Number	:	231-941-7500
Fax Number	:	231-940-7509

Provider Business Practice Location Address
First Line	:	4020 COPPER VW STE 212
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7041
Country	:	US
Telephone Number	:	231-941-7500
Fax Number	:	231-941-7509

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID AMALFITANO
Credential	:	M.D.
Telephone Number	:	231-941-7500

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	10/16/2014

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Directions to “VEIN CENTER AND MEDICAL SPA ” Practice Location

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