Healthcare Provider Details

I. General information

NPI: 1265017446
Provider Name (Legal Business Name): VASCULAR CENTER OF THE MIDWEST (VCM), LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 WOODMAN DR STE 320
DAYTON OH
45420-1171
US

IV. Provider business mailing address

78 PARK RD
OAKWOOD OH
45419-3001
US

V. Phone/Fax

Practice location:
  • Phone: 937-795-1090
  • Fax: 937-795-1145
Mailing address:
  • Phone: 858-829-4072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANKAR M SUNDARAM
Title or Position: PRESIDENT
Credential:
Phone: 858-829-4072