Organization
INNOVAMED VEINS SC
Active
Organization
INNOVAMED VEINS SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TRACY C BRITO M.D. (OWNER)
(815) 987-1802
Entity
Organization
Contact information
Practice address
2601 N MAIN ST, ROCKFORD, IL 61103-3110
(815) 987-1802
(815) 987-1806
Mailing address
2601 N MAIN ST, ROCKFORD, IL 61103-3110
(815) 987-1802
(815) 987-1806
Taxonomy
Speciality
Code
Description
License number
State
202K00000X
Phlebology Physician
036074111
IL
207R00000X
Internal Medicine Physician
Primary
036074111
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036074111
—
IL
Enumeration date
03/06/2009
Last updated
06/04/2009
Update your record
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