Provider Demographics
NPI:1104361799
Name:BILAL A ITANI MD PLLC
Entity Type:Organization
Organization Name:BILAL A ITANI MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BILAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ITANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-788-0202
Mailing Address - Street 1:233 S MINERAL ST
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-2643
Mailing Address - Country:US
Mailing Address - Phone:304-788-0202
Mailing Address - Fax:304-788-4377
Practice Address - Street 1:233 S MINERAL ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2643
Practice Address - Country:US
Practice Address - Phone:304-788-0202
Practice Address - Fax:304-788-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16425208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0043316000Medicaid