Basic Information
| Provider Information | |||||||||
| NPI: | 1407162696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | A E LANDIS MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 417 CARRIAGE DR | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258012805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042550459 | ||||||||
| FaxNumber: | 3042523471 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 CARRIAGE DR | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258012805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042550459 | ||||||||
| FaxNumber: | 3042523471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | LANDIS | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3042550459 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 11229 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 1043284110 | 05 | WV | MEDICAID |