MEDICARE: INDIANA PHLEBOLOGY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	202K00000X	Phlebology Physician	IN
2	2085R0204X	Vascular & Interventional Radiology Physician	IN
3	2086S0129X	Vascular Surgery Physician	IN
4	208600000X	Surgery Physician	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DO6229	OTHER	IN	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1962508853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA PHLEBOLOGY PC

Provider Business Mailing Address
First Line	:	PO BOX 451
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60065-0451
Country	:	US
Telephone Number	:	847-593-8460
Fax Number	:	877-285-5883

Provider Business Practice Location Address
First Line	:	371 E 84TH DR STE 371
Second Line	:
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-6484
Country	:	US
Telephone Number	:	219-736-7165
Fax Number	:

Authorized Official
Title or Position	:	SR VP REVENUE
Name	:	NATHAN AMORUSO
Credential	:
Telephone Number	:	847-593-8460

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	05/04/2023

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Directions to “INDIANA PHLEBOLOGY PC ” Practice Location

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