Provider Demographics
NPI:1275008856
Name:APPALACHIAN ADDICTION MEDICAL PLLC
Entity Type:Organization
Organization Name:APPALACHIAN ADDICTION MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-896-5200
Mailing Address - Street 1:77 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 100 KRUGER BUILDING
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601
Mailing Address - Country:US
Mailing Address - Phone:304-896-5200
Mailing Address - Fax:304-896-5300
Practice Address - Street 1:77 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 100 KRUGER BUILDING
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601
Practice Address - Country:US
Practice Address - Phone:304-896-5200
Practice Address - Fax:304-896-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Single Specialty