Healthcare Provider Details

I. General information

NPI: 1174171441
Provider Name (Legal Business Name): MODERN VASCULAR OF SOUTHAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PHYSICIANS LN
SOUTHAVEN MS
38671-9569
US

IV. Provider business mailing address

26500 AGOURA RD STE 201
CALABASAS CA
91302-3556
US

V. Phone/Fax

Practice location:
  • Phone: 662-655-2136
  • Fax: 662-996-2214
Mailing address:
  • Phone: 818-880-8605
  • Fax: 818-579-7916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: YURY GAMPEL
Title or Position: MANAGER
Credential:
Phone: 818-880-8605