Provider Demographics
NPI:1609216605
Name:PEDIATRIC GASTROENTEROLOGY OF CHARLESTON, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY OF CHARLESTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHSHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-400-4626
Mailing Address - Street 1:428 DIVISION ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1469
Mailing Address - Country:US
Mailing Address - Phone:304-400-4626
Mailing Address - Fax:
Practice Address - Street 1:428 DIVISION ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1469
Practice Address - Country:US
Practice Address - Phone:304-400-4626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV244182080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV381002088Medicaid
WV381002088Medicaid
WV0491AMedicare PIN