Provider Demographics
NPI:1043493224
Name:MIDWEST VASCULAR AND ENDOVASCULAR SURGERY PC
Entity Type:Organization
Organization Name:MIDWEST VASCULAR AND ENDOVASCULAR SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHAMBERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-644-2202
Mailing Address - Street 1:1031 BELLEVUE AVE
Mailing Address - Street 2:SUITE 349
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1818
Mailing Address - Country:US
Mailing Address - Phone:314-644-2202
Mailing Address - Fax:314-644-3155
Practice Address - Street 1:1031 BELLEVUE AVE
Practice Address - Street 2:SUITE 349
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1818
Practice Address - Country:US
Practice Address - Phone:314-644-2202
Practice Address - Fax:314-644-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1089882086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG05280Medicare UPIN