Provider Demographics
NPI:1538791793
Name:VASCULAR SURGERY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:VASCULAR SURGERY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:ELLENBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-346-9533
Mailing Address - Street 1:10258 SOUTHWEST HWY STE A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-1361
Mailing Address - Country:US
Mailing Address - Phone:708-346-9533
Mailing Address - Fax:708-499-4312
Practice Address - Street 1:10258 SOUTHWEST HWY STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1361
Practice Address - Country:US
Practice Address - Phone:708-346-9533
Practice Address - Fax:708-499-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001538791793Medicaid