Basic Information
| Provider Information | |||||||||
| NPI: | 1255438461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY INTERNAL MEDICINE PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 26391 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049152014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174021000 | ||||||||
| FaxNumber: | 8888644428 | ||||||||
| Practice Location | |||||||||
| Address1: | 3737 W MAIN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241532072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403803722 | ||||||||
| FaxNumber: | 5403803725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAZA | ||||||||
| AuthorizedOfficialFirstName: | SYED | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5403803725 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH8125 | 01 | MEDICARE RAILROAD | OTHER |