Healthcare Provider Details

I. General information

NPI: 1588146211
Provider Name (Legal Business Name): GOMELB VASCULAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 205
SAINT LOUIS MO
63141-8670
US

IV. Provider business mailing address

12855 N 40 DR STE 205
SAINT LOUIS MO
63141-8670
US

V. Phone/Fax

Practice location:
  • Phone: 314-255-2204
  • Fax: 866-623-8346
Mailing address:
  • Phone: 314-255-2204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number2016010164
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2471C1101X
TaxonomyCardiovascular-Interventional Technology Radiologic Technologist
License Number201610164
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number2016010164
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number2016010164
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: OLAGUOKE AKINWANDE
Title or Position: PROVIDER
Credential: MD
Phone: 410-499-1078