Provider Demographics
NPI:1902995210
Name:LASER VEIN INSTITUTE SC
Entity Type:Organization
Organization Name:LASER VEIN INSTITUTE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:TOLITANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-860-0035
Mailing Address - Street 1:777 OAKMONT LN
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5511
Mailing Address - Country:US
Mailing Address - Phone:630-789-2550
Mailing Address - Fax:
Practice Address - Street 1:311 N WALNUT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1566
Practice Address - Country:US
Practice Address - Phone:630-860-0035
Practice Address - Fax:630-860-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDG2072OtherRAILROAD MEDICARE
IL2232802OtherBCBS PROVIDER ID
ILDG2072OtherRAILROAD MEDICARE
IL2232802OtherBCBS PROVIDER ID
IL209848Medicare PIN