Provider Demographics
NPI:1326255589
Name:KANAWHA MEDICAL CLINIC
Entity Type:Organization
Organization Name:KANAWHA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMAL
Authorized Official - Middle Name:F
Authorized Official - Last Name:SAKKAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-346-1410
Mailing Address - Street 1:331 LAIDLEY ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1619
Mailing Address - Country:US
Mailing Address - Phone:304-346-1410
Mailing Address - Fax:304-344-0188
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:SUITE 406
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-346-1410
Practice Address - Fax:304-344-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19073174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0080971000Medicaid
WV0080971000Medicaid
WV0838452Medicare ID - Type Unspecified