Provider Demographics
NPI:1356448534
Name:THE VASCULAR CLINIC & COSMETIC VEIN TREATMENT CENTER PL
Entity type:Organization
Organization Name:THE VASCULAR CLINIC & COSMETIC VEIN TREATMENT CENTER PL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:HANNUM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-518-4982
Mailing Address - Street 1:PO BOX 620696
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32862-0696
Mailing Address - Country:US
Mailing Address - Phone:407-518-4982
Mailing Address - Fax:407-518-1748
Practice Address - Street 1:720 W OAK ST STE 309
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4910
Practice Address - Country:US
Practice Address - Phone:407-518-4982
Practice Address - Fax:407-518-1748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS87402086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17027OtherBCBS
FL264703600Medicaid
FL264703600Medicaid
FLAC947Medicare PIN