=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952590432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIJAYKUMAR R PHADE MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2007
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 496 CHERRY ST BLDG C STE A
-----------------------------------------------------
City | BLUEFIELD
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24701-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-327-7476
-----------------------------------------------------
Fax | 304-327-7476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1553
-----------------------------------------------------
City | BLUEFIELD
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24701-1553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-327-7476
-----------------------------------------------------
Fax | 304-327-7476
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VIJAYKUMAR R PHADE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 304-327-7476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 12519
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 12519
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------