Healthcare Provider Details

I. General information

NPI: 1497887350
Provider Name (Legal Business Name): AMERICAN INSTITUTE FOR DISEASES OF THE PROSTATE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 BENT OAKS DR
EARLYSVILLE VA
22936
US

IV. Provider business mailing address

PO BOX 195
EARLYSVILLE VA
22936-0195
US

V. Phone/Fax

Practice location:
  • Phone: 434-964-0212
  • Fax: 434-964-0216
Mailing address:
  • Phone: 434-964-0212
  • Fax: 434-964-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101050527
License Number StateVA

VIII. Authorized Official

Name: DR. CHARLES E MYERS JR.
Title or Position: DIRECTOR
Credential: M.D.
Phone: 434-964-0212