Provider Demographics
NPI:1811587132
Name:MODERN VASCULAR OF MEMPHIS LLC
Entity Type:Organization
Organization Name:MODERN VASCULAR OF MEMPHIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-262-6423
Mailing Address - Street 1:26500 AGOURA RD STE 102-587
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1952
Mailing Address - Country:US
Mailing Address - Phone:818-880-8605
Mailing Address - Fax:
Practice Address - Street 1:5645 MURRAY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3831
Practice Address - Country:US
Practice Address - Phone:901-633-1190
Practice Address - Fax:901-881-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional TechnologyGroup - Single Specialty
No2471C1101XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiovascular-Interventional TechnologyGroup - Single Specialty