Provider Demographics
NPI:1407162696
Name:A E LANDIS MD PC
Entity Type:Organization
Organization Name:A E LANDIS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:E
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-255-0459
Mailing Address - Street 1:417 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2805
Mailing Address - Country:US
Mailing Address - Phone:304-255-0459
Mailing Address - Fax:304-252-3471
Practice Address - Street 1:417 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-255-0459
Practice Address - Fax:304-252-3471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11229261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1043284110Medicaid
WV1043284110Medicaid
WV0442475Medicare PIN