Basic Information
Provider Information | |||||||||
NPI: | 1669653796 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VAIDYA UROLOGY CLINIC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2520 VALLEY DRIVE | ||||||||
Address2: | SUITE 016 | ||||||||
City: | POINT PLEASANT | ||||||||
State: | WV | ||||||||
PostalCode: | 25550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046756060 | ||||||||
FaxNumber: | 3046755001 | ||||||||
Practice Location | |||||||||
Address1: | 2520 VALLEY DRIVE | ||||||||
Address2: | SUITE 016 | ||||||||
City: | POINT PLEASANT | ||||||||
State: | WV | ||||||||
PostalCode: | 25550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046756060 | ||||||||
FaxNumber: | 3046755001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2007 | ||||||||
LastUpdateDate: | 06/27/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONG | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3046756060 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 13842 | WV | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
ID | Type | State | Issuer | Description | 340018637 | 01 | WV | TRAVELERS MEDICARE | OTHER | 001707383 | 01 | WV | MOUNTAIN STATE BCBS | OTHER | 0131036000 | 05 | WV |   | MEDICAID | 0544987 | 05 | OH |   | MEDICAID |