Healthcare Provider Details

I. General information

NPI: 1760943047
Provider Name (Legal Business Name): GOMELB VASCULAR CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 S BROADWAY
SAINT LOUIS MO
63118-4601
US

IV. Provider business mailing address

9006 STONEBRIDGE DR
RICHMOND HEIGHTS MO
63117-1025
US

V. Phone/Fax

Practice location:
  • Phone: 314-865-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C1101X
TaxonomyCardiovascular-Interventional Technology Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number
License Number State

VIII. Authorized Official

Name: OLAGUOKE AKINWANDE
Title or Position: CEO
Credential: MD
Phone: 314-380-3099