1285602862 NPI number — DR. MYRON EDWARD ELLER JR. M.D.

Table of content: DR. PATRICIA DAZA PHD (NPI 1306045299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285602862 NPI number — DR. MYRON EDWARD ELLER JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLER
Provider First Name:
MYRON
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1285602862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 COMMONWEALTH BLVD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24112-2014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-632-3841
Provider Business Mailing Address Fax Number:
276-632-2437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 COMMONWEALTH BLVD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24112-2014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-632-3841
Provider Business Practice Location Address Fax Number:
276-632-2437
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101035560 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 005615585 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 466796 . This is a "ANTHEM GROUP NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0103709 . This is a "UNITED HEALTHCARE PROVIDE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 080018160 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 005615585 . This is a "VIRGINIA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 466798 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2128061 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: CB1505 . This is a "RAILROAD MEDICARE GROUP #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0164R . This is a "BCBS OF NC COSTWISE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 101806 . This is a "CIGNA PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 226029 . This is a "SOUTHERN HEALTH PROVIDER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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