1952590432 NPI number — VIJAYKUMAR R PHADE MD PC

Table of content: (NPI 1952590432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952590432 NPI number — VIJAYKUMAR R PHADE MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIJAYKUMAR R PHADE MD PC
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:
VIJAYKUMAR R. PHADE MD
Provider Other Organization Name Type Code:
4
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:
1952590432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1553
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUEFIELD
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24701-1553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-327-7476
Provider Business Mailing Address Fax Number:
304-327-7476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
496 CHERRY ST
Provider Second Line Business Practice Location Address:
BLDG C STE A
Provider Business Practice Location Address City Name:
BLUEFIELD
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24701-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-327-7476
Provider Business Practice Location Address Fax Number:
304-327-7476
Provider Enumeration Date:
10/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHADE
Authorized Official First Name:
VIJAYKUMAR
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-327-7476

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  12519 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X , with the licence number: 12519 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 020000431 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 007394322 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0128227000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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