1982876587 NPI number — INTERNAL MEDICINE & GERIATRIC SPECIALISTS, INC.

Table of content: (NPI 1982876587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982876587 NPI number — INTERNAL MEDICINE & GERIATRIC SPECIALISTS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE & GERIATRIC SPECIALISTS, 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:
6
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:
1982876587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1004 TAVERN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25401-2864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-264-4433
Provider Business Mailing Address Fax Number:
304-264-4446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1004 TAVERN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25401-2864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-264-4433
Provider Business Practice Location Address Fax Number:
304-264-4446
Provider Enumeration Date:
03/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
QUE
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
CLINTON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-264-4433

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  23821 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 20638 , 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: 3810011501 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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