Basic Information
| Provider Information | |||||||||
| NPI: | 1346214913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOLL | ||||||||
| FirstName: | SYAM | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4190 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255044190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043994405 | ||||||||
| FaxNumber: | 3043992526 | ||||||||
| Practice Location | |||||||||
| Address1: | 2827 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043997182 | ||||||||
| FaxNumber: | 3045237738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 21729 | WV | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 9486104 | 01 | WV | AETNA | OTHER | 3810010997 | 05 | WV | MEDICAID |