Provider Demographics
NPI:1952590432
Name:VIJAYKUMAR R PHADE MD PC
Entity Type:Organization
Organization Name:VIJAYKUMAR R PHADE MD PC
Other - Org Name:VIJAYKUMAR R. PHADE MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYKUMAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-327-7476
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-1553
Mailing Address - Country:US
Mailing Address - Phone:304-327-7476
Mailing Address - Fax:304-327-7476
Practice Address - Street 1:496 CHERRY ST
Practice Address - Street 2:BLDG C STE A
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3304
Practice Address - Country:US
Practice Address - Phone:304-327-7476
Practice Address - Fax:304-327-7476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12519208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV020000431OtherRAILROAD MEDICARE
VA007394322Medicaid
WV0128227000Medicaid
WV020000431OtherRAILROAD MEDICARE
WV0128227000Medicaid