Active NPI
Champ Vascular, LLC
- Interventional Cardiology Physician
- Newnan, GA
National Provider Identifier
1669019394
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Interventional Cardiology Physician
- Legal business name
- CHAMP VASCULAR, LLC
- Practice address
- 1825 Highway 34 E Ste 3400
Newnan, GA 30265-6423 - Phone
- (770) 500-9588
- NPI assigned
- Dec 2, 2019
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Oghenerukevwe Odiete
- Title
- MD Owner
- Phone
- (770) 400-9588
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Interventional Cardiology Physician | 207RI0011X | Primary |
Addresses
Primary practice location
1825 Highway 34 E Ste 3400
Newnan, GA 30265-6423
Mailing address
124 Morgan Dr
Lagrange, GA 30240-6361
Other names 1
- Peachstate Advanced Cardiac and Endovascular LLC
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in GA
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20200114000038 | GA | Part B Supplier - Clinic/Group Practice | 0749615177 |
Receives reassigned benefits from 4 practitioners Practice locations: Newnan, GA |
National Provider Directory
National Provider DirectoryPractitioners & affiliated clinicians
Practitioners 4
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Interventional Cardiology Physician
- Newnan, GA
- NPI 1265758502
GA, Interventional Cardiology
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1575244800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1746489600000",
"number": "1669019394",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "124 MORGAN DR",
"city": "LAGRANGE",
"state": "GA",
"postal_code": "302406361"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1825 HIGHWAY 34 E STE 3400",
"city": "NEWNAN",
"state": "GA",
"postal_code": "302656423",
"telephone_number": "770-500-9588"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "CHAMP VASCULAR, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2019-12-02",
"last_updated": "2025-05-06",
"certification_date": "2025-05-06",
"status": "A",
"authorized_official_last_name": "ODIETE",
"authorized_official_first_name": "OGHENERUKEVWE",
"authorized_official_title_or_position": "MD OWNER",
"authorized_official_telephone_number": "770-400-9588"
},
"taxonomies": [
{
"code": "207RI0011X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Internal Medicine, Interventional Cardiology",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "Peachstate Advanced Cardiac and Endovascular LLC",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Newnan, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.