1306064118 NPI number — INSTITUTE OF DISABILITY MEDICINE INC.

Table of content: (NPI 1306064118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306064118 NPI number — INSTITUTE OF DISABILITY MEDICINE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INSTITUTE OF DISABILITY MEDICINE INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306064118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 MEDICAL PARK
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26003-6392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-242-2503
Provider Business Mailing Address Fax Number:
304-242-2682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 MEDICAL PARK
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-6392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-242-2503
Provider Business Practice Location Address Fax Number:
304-242-2682
Provider Enumeration Date:
04/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOVINDAN
Authorized Official First Name:
SRINI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-242-2503

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  9751 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0090961000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9751 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".