Provider Demographics
NPI:1346541281
Name:SOUTHERN WEST VIRGINIA NEPHROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHERN WEST VIRGINIA NEPHROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:B
Authorized Official - Last Name:FARIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-752-8800
Mailing Address - Street 1:300 PROSPERITY LN
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3743
Mailing Address - Country:US
Mailing Address - Phone:304-752-8800
Mailing Address - Fax:304-752-9000
Practice Address - Street 1:300 PROSPERITY LN
Practice Address - Street 2:SUITE 203
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3494
Practice Address - Country:US
Practice Address - Phone:304-752-8800
Practice Address - Fax:304-752-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22245207RN0300X
KY42343207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty