Provider Demographics
NPI:1871895474
Name:MARTINEZ VEIN CENTER
Entity type:Organization
Organization Name:MARTINEZ VEIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-483-0665
Mailing Address - Street 1:PO BOX 8268
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-8268
Mailing Address - Country:US
Mailing Address - Phone:630-483-0665
Mailing Address - Fax:630-483-0526
Practice Address - Street 1:114 BARTLETT PLZ
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4234
Practice Address - Country:US
Practice Address - Phone:630-483-0665
Practice Address - Fax:630-483-0526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099034305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36099034Medicaid
IL36099034Medicaid