Provider Demographics
NPI:1497887350
Name:AMERICAN INSTITUTE FOR DISEASES OF THE PROSTATE, PLC
Entity Type:Organization
Organization Name:AMERICAN INSTITUTE FOR DISEASES OF THE PROSTATE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:434-964-0212
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:EARLYSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22936-0195
Mailing Address - Country:US
Mailing Address - Phone:434-964-0212
Mailing Address - Fax:434-964-0216
Practice Address - Street 1:690 BENT OAKS DR
Practice Address - Street 2:
Practice Address - City:EARLYSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22936
Practice Address - Country:US
Practice Address - Phone:434-964-0212
Practice Address - Fax:434-964-0216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF75094Medicare UPIN