MEDICARE: VASCULAR INTERVENTIONAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist
2	2085R0204X	Vascular & Interventional Radiology Physician

General Provider Information

NPI Number	:	1508363714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VASCULAR INTERVENTIONAL GROUP, INC.

Provider Business Mailing Address
First Line	:	18375 VENTURA BLVD STE 554
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-4218
Country	:	US
Telephone Number	:	818-259-1138
Fax Number	:	818-583-1696

Provider Business Practice Location Address
First Line	:	6601 RUGBY AVE STE 100
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4040
Country	:	US
Telephone Number	:	818-949-2631
Fax Number	:	818-691-2932

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	VLADIMIR ZEETSER
Credential	:	DPM
Telephone Number	:	818-259-1138

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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