Provider Demographics
NPI:1285011544
Name:SUB-CLINIC, INC
Entity Type:Organization
Organization Name:SUB-CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KALOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-926-2300
Mailing Address - Street 1:5240 1/2 MCCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-926-2300
Mailing Address - Fax:304-926-2304
Practice Address - Street 1:5240 1/2 MCCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-926-2300
Practice Address - Fax:304-926-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I63345Medicare UPIN