Provider Demographics
NPI:1306064118
Name:INSTITUTE OF DISABILITY MEDICINE INC.
Entity type:Organization
Organization Name:INSTITUTE OF DISABILITY MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRINI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVINDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-242-2503
Mailing Address - Street 1:40 MEDICAL PARK
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6392
Mailing Address - Country:US
Mailing Address - Phone:304-242-2503
Mailing Address - Fax:304-242-2682
Practice Address - Street 1:40 MEDICAL PARK
Practice Address - Street 2:SUITE 304
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6392
Practice Address - Country:US
Practice Address - Phone:304-242-2503
Practice Address - Fax:304-242-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV9751174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0090961000Medicaid
WV9751OtherSTATE LICENSE NUMBER
WV0090961000Medicaid
WV0463112Medicare PIN