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Organization
MODERN VASCULAR OF SOUTHAVEN, LLC
Active
Organization
MODERN VASCULAR OF SOUTHAVEN, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
YURY GAMPEL (MANAGER)
(818) 880-8605
Entity
Organization
Contact information
Practice address
55 PHYSICIANS LN, SOUTHAVEN, MS 38671-9569
(662) 655-2136
(662) 996-2214
Mailing address
26500 AGOURA RD STE 201, CALABASAS, CA 91302-3556
(818) 880-8605
(818) 579-7916
Taxonomy
Speciality
Code
Description
License number
State
2085R0204X
Vascular & Interventional Radiology Physician
Primary
—
NULL
2085R0204X
Vascular & Interventional Radiology Physician
Primary
—
—
2471V0106X
Vascular-Interventional Technology Radiologic Technologist
—
NULL
2471V0106X
Vascular-Interventional Technology Radiologic Technologist
—
—
Other
Enumeration date
08/29/2019
Last updated
08/29/2019
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