Provider Demographics
NPI:1679878805
Name:TRI-STATE VEIN CENTER
Entity type:Organization
Organization Name:TRI-STATE VEIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-583-8346
Mailing Address - Street 1:505 CEDAR CROSS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52003-7704
Mailing Address - Country:US
Mailing Address - Phone:563-583-8346
Mailing Address - Fax:563-557-3710
Practice Address - Street 1:505 CEDAR CROSS RD
Practice Address - Street 2:SUITE A
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003-7704
Practice Address - Country:US
Practice Address - Phone:563-583-8346
Practice Address - Fax:563-557-3710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26573208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2069948Medicaid
WI32029700Medicaid
IA2069948Medicaid
WI32029700Medicaid