Provider Demographics
NPI:1427390608
Name:VASCULAR INTERVENTIONAL PAVILION, LLC
Entity Type:Organization
Organization Name:VASCULAR INTERVENTIONAL PAVILION, LLC
Other - Org Name:V.I.P.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:727-527-5100
Mailing Address - Street 1:3520 38TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-1448
Mailing Address - Country:US
Mailing Address - Phone:727-527-5100
Mailing Address - Fax:727-527-5119
Practice Address - Street 1:3500 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-1448
Practice Address - Country:US
Practice Address - Phone:727-527-5100
Practice Address - Fax:727-527-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106833208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty