MEDICARE: PREMIER VEIN CENTER 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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1912906371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER VEIN CENTER LLC

Provider Business Mailing Address
First Line	:	520 E 22ND ST
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-6110
Country	:	US
Telephone Number	:	630-874-2542
Fax Number	:

Provider Business Practice Location Address
First Line	:	1051 W RAND RD
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-2315
Country	:	US
Telephone Number	:	847-618-1000
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	EVAN S. OBLONSKY
Credential	:	M.D.
Telephone Number	:	847-618-1000

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	07/16/2007

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