Provider Demographics
NPI:1164482774
Name:JANUSZKIEWICZ, SAMUEL A (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:JANUSZKIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE B500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1500
Mailing Address - Fax:304-691-1510
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:SUITE B500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-1500
Practice Address - Fax:304-691-1510
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13405207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0635398Medicaid
WV0114367000Medicaid
WVA72436Medicare UPIN
WV0587225Medicare ID - Type Unspecified