Provider Demographics
NPI:1104005297
Name:EMMANUEL O. SOYOOLA MD PC
Entity Type:Organization
Organization Name:EMMANUEL O. SOYOOLA MD PC
Other - Org Name:OLAN COMPREHENSIVE WOMENS HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:OLUSOLA
Authorized Official - Last Name:SOYOOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD,FACOG
Authorized Official - Phone:304-752-6780
Mailing Address - Street 1:PO BOX 536
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-0536
Mailing Address - Country:US
Mailing Address - Phone:304-752-6780
Mailing Address - Fax:304-752-6782
Practice Address - Street 1:70 HOSPITAL DR
Practice Address - Street 2:KRUGER MEDICAL PLAZA, SUITE 200
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3452
Practice Address - Country:US
Practice Address - Phone:304-752-6780
Practice Address - Fax:304-752-6782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21399207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1811315000Medicaid
WV1811315000Medicaid