Provider Demographics
NPI:1184782989
Name:GRADUATE VASCULAR AND ENDOVASCULAR ASSOCIATES, LLC
Entity type:Organization
Organization Name:GRADUATE VASCULAR AND ENDOVASCULAR ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:MANTELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-893-2996
Mailing Address - Street 1:51 N 39TH ST
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-893-2996
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-893-2996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG30376Medicare UPIN
PA054356Medicare PIN
NJ058507Medicare PIN