Provider Demographics
NPI:1265017446
Name:VASCULAR CENTER OF THE MIDWEST (VCM), LLC
Entity type:Organization
Organization Name:VASCULAR CENTER OF THE MIDWEST (VCM), LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANKAR
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUNDARAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-829-4072
Mailing Address - Street 1:78 PARK RD
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3001
Mailing Address - Country:US
Mailing Address - Phone:858-829-4072
Mailing Address - Fax:
Practice Address - Street 1:3085 WOODMAN DR STE 320
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1171
Practice Address - Country:US
Practice Address - Phone:937-795-1090
Practice Address - Fax:937-795-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH868720OtherMEDICARE PTAN
OHH868720OtherMEDICARE PTAN