Provider Demographics
NPI:1275810830
Name:DIABETES, ENDOCRINOLOGY & LIPIDOLOGY CENTER, INC.
Entity Type:Organization
Organization Name:DIABETES, ENDOCRINOLOGY & LIPIDOLOGY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-260-1060
Mailing Address - Street 1:176 HEALTH CARE LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-4010
Mailing Address - Country:US
Mailing Address - Phone:304-260-1060
Mailing Address - Fax:304-260-1062
Practice Address - Street 1:176 HEALTH CARE LN
Practice Address - Street 2:SUITE B
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-4010
Practice Address - Country:US
Practice Address - Phone:304-260-1060
Practice Address - Fax:304-260-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21393207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810022262Medicaid
WV1275810830Medicare PIN
WVWV0833A548Medicare PIN