Basic Information
| Provider Information | |||||||||
| NPI: | 1770972598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VASCULAR INTERVENTIONS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8865 W 400 N | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463609222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198772225 | ||||||||
| FaxNumber: | 2198772230 | ||||||||
| Practice Location | |||||||||
| Address1: | 8865 W 400 N | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463609222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198772225 | ||||||||
| FaxNumber: | 2198772230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2015 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | TATTERSALL | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2198772225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.