Provider Demographics
NPI:1669653796
Name:VAIDYA UROLOGY CLINIC INC
Entity type:Organization
Organization Name:VAIDYA UROLOGY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-675-6060
Mailing Address - Street 1:2520 VALLEY DRIVE
Mailing Address - Street 2:SUITE 016
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550
Mailing Address - Country:US
Mailing Address - Phone:304-675-6060
Mailing Address - Fax:304-675-5001
Practice Address - Street 1:2520 VALLEY DRIVE
Practice Address - Street 2:SUITE 016
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550
Practice Address - Country:US
Practice Address - Phone:304-675-6060
Practice Address - Fax:304-675-5001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13842261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV340018637OtherTRAVELERS MEDICARE
WV001707383OtherMOUNTAIN STATE BCBS
WV0131036000Medicaid
OH0544987Medicaid
WV9314313Medicare PIN
WV9314312Medicare PIN
OH0544987Medicaid