Provider Demographics
NPI:1679767610
Name:ADVANCED VASCULAR AND VEIN CENTER LLC
Entity type:Organization
Organization Name:ADVANCED VASCULAR AND VEIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-552-3015
Mailing Address - Street 1:17404 BURKE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2242
Mailing Address - Country:US
Mailing Address - Phone:531-466-4260
Mailing Address - Fax:531-466-4304
Practice Address - Street 1:17404 BURKE ST STE 102
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2242
Practice Address - Country:US
Practice Address - Phone:531-466-4260
Practice Address - Fax:531-466-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
IAIB2289Medicare PIN
NE=========00Medicaid