Provider Demographics
NPI:1932230703
Name:ISLAND MEDICAL SERVICE INC
Entity Type:Organization
Organization Name:ISLAND MEDICAL SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIL
Authorized Official - Middle Name:P
Authorized Official - Last Name:PAPADIMITRIOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-232-2100
Mailing Address - Street 1:103 S PENN ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2075
Mailing Address - Country:US
Mailing Address - Phone:304-232-2100
Mailing Address - Fax:304-232-8272
Practice Address - Street 1:103 S PENN ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2075
Practice Address - Country:US
Practice Address - Phone:304-232-2100
Practice Address - Fax:304-232-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV8646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6693636Medicaid
WV0055704000Medicaid
WVB42478Medicare UPIN
WV0055704000Medicaid