Provider Demographics
NPI:1659524635
Name:ADVANCED DIABETES & ENDOCRINE CENTER
Entity Type:Organization
Organization Name:ADVANCED DIABETES & ENDOCRINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:N
Authorized Official - Last Name:HAQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-933-3864
Mailing Address - Street 1:527 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9009
Mailing Address - Country:US
Mailing Address - Phone:304-933-3864
Mailing Address - Fax:304-933-3867
Practice Address - Street 1:527 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9009
Practice Address - Country:US
Practice Address - Phone:304-933-3864
Practice Address - Fax:304-933-3867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19842207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV19842OtherSTATE LICENSE