MEDICARE: DIMITRI MISAILIDIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	15875	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000848955	OTHER	WV	WV BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053356204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIMITRI MISAILIDIS MD

Provider Business Mailing Address
First Line	:	300 FOXCROFT AVE
Second Line	:	SUITE 202B
City	:	MARTINSBURG
State	:	WV
Zip	:	25401-5341
Country	:	US
Telephone Number	:	304-263-4967
Fax Number	:	304-267-5461

Provider Business Practice Location Address
First Line	:	300 FOXCROFT AVE
Second Line	:	SUITE 202B
City	:	MARTINSBURG
State	:	WV
Zip	:	25401-5341
Country	:	US
Telephone Number	:	304-263-4967
Fax Number	:	304-267-5461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	02/01/2013

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