Provider Demographics
NPI:1225010861
Name:WASYLYK, IRENE M (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:M
Last Name:WASYLYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3624
Mailing Address - Country:US
Mailing Address - Phone:304-255-9444
Mailing Address - Fax:304-255-9447
Practice Address - Street 1:224 PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3624
Practice Address - Country:US
Practice Address - Phone:304-255-9446
Practice Address - Fax:304-255-9447
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233309207R00000X
WV22010207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH75511Medicare UPIN
WVH75511Medicare UPIN