Provider Demographics
NPI:1326143306
Name:DIABETES, ENDOCRINE AND INTERNAL MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:DIABETES, ENDOCRINE AND INTERNAL MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-272-7565
Mailing Address - Street 1:1475 JOHNSTON WILLIS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4730
Mailing Address - Country:US
Mailing Address - Phone:804-272-7564
Mailing Address - Fax:804-272-9325
Practice Address - Street 1:1475 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-272-7564
Practice Address - Fax:804-272-9325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101026634207R00000X
VA0101025435207RE0101X
VA0101237679207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC00810Medicare PIN