Provider Demographics
NPI:1093742611
Name:AMANDEEP S. PUREWAL, LLC
Entity Type:Organization
Organization Name:AMANDEEP S. PUREWAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDEEP
Authorized Official - Middle Name:S
Authorized Official - Last Name:PUREWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-723-4041
Mailing Address - Street 1:485 COLLIERS WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5012
Mailing Address - Country:US
Mailing Address - Phone:304-723-4041
Mailing Address - Fax:304-723-9607
Practice Address - Street 1:485 COLLIERS WAY
Practice Address - Street 2:SUITE B
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5012
Practice Address - Country:US
Practice Address - Phone:304-723-4041
Practice Address - Fax:304-723-9607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19873207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011697Medicaid
WVAM9375521Medicare PIN
WV3810011697Medicaid