Provider Demographics
NPI:1619065190
Name:KALOU, MOHAMAD SAMAH (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:SAMAH
Last Name:KALOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 POPLAR ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1474
Mailing Address - Country:US
Mailing Address - Phone:304-767-7840
Mailing Address - Fax:304-767-7849
Practice Address - Street 1:5240 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2122
Practice Address - Country:US
Practice Address - Phone:304-926-2300
Practice Address - Fax:304-926-2304
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22493207Q00000X, 207QA0401X
OH35.088590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001902627OtherBCBS
WV3810006491Medicaid
WV4194912Medicare PIN
WV3810006491Medicaid