Provider Demographics
NPI:1346214913
Name:STOLL, SYAM B (MD)
Entity Type:Individual
Prefix:
First Name:SYAM
Middle Name:B
Last Name:STOLL
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:PO BOX 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:2827 5TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1435
Practice Address - Country:US
Practice Address - Phone:304-399-7182
Practice Address - Fax:304-523-7738
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21729208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9486104OtherAETNA
WV3810010997Medicaid
I18633Medicare UPIN
WV2025771Medicare PIN