Provider Demographics
NPI:1588146211
Name:GOMELB VASCULAR LLC
Entity type:Organization
Organization Name:GOMELB VASCULAR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:OLAGUOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:AKINWANDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-499-1078
Mailing Address - Street 1:12855 N 40 DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8670
Mailing Address - Country:US
Mailing Address - Phone:314-255-2204
Mailing Address - Fax:
Practice Address - Street 1:12855 N 40 DR STE 205
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8670
Practice Address - Country:US
Practice Address - Phone:314-255-2204
Practice Address - Fax:866-623-8346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-29
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 2085R0204X, 2086S0129X
MO2016101642471C1101X
MO20160101642471N0900X, 2471V0106X, 246XC2903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular SpecialistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No2471C1101XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiovascular-Interventional TechnologyGroup - Multi-Specialty
No2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Multi-Specialty
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional TechnologyGroup - Multi-Specialty