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General NPI Number Information
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NPI Number | 1164664702
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Entity Type | Organization
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Legal Business Name | MEDSTAT INC
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Dates
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Enumeration Date | 03/28/2009
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Last Update Date | 03/28/2009
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Provider Practice Location Address
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Address Line | 433B S SYCAMORE ST
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City | PETERSBURG
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State | VA
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Zip | 23803-5042
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Country | US
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Telephone | 804-732-0248
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Fax | 804-732-8475
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Provider Business Mailing Address
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Address Line | 433B S SYCAMORE ST
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City | PETERSBURG
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State | VA
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Zip | 23803-5042
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Country | US
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Telephone | 804-732-0248
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Fax | 804-732-8475
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. ENIOLA ADEBAYO OKELANA
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Credential | MD, FCCP
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Telephone | 804-732-0248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 0101052627
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License Number State | VA
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