Provider Demographics
NPI:1326044413
Name:SHAMMA, BASSAM NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:NICHOLAS
Last Name:SHAMMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 MACCORKLE AVE SW
Mailing Address - Street 2:STE 301
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1364
Mailing Address - Country:US
Mailing Address - Phone:304-767-7919
Mailing Address - Fax:304-767-7911
Practice Address - Street 1:4607 MACCORKLE AVE SW
Practice Address - Street 2:STE 301
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-767-7919
Practice Address - Fax:304-767-7911
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16982207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0092235000Medicaid
WV0092235000Medicaid
WVF35039Medicare UPIN