Provider Demographics
NPI:1689808925
Name:RALEIGH LUNG CLINIC INCORPORATED PC
Entity Type:Organization
Organization Name:RALEIGH LUNG CLINIC INCORPORATED PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMZI
Authorized Official - Middle Name:N
Authorized Official - Last Name:HADDADIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-255-6300
Mailing Address - Street 1:43 FOX SPARROW RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3687
Mailing Address - Country:US
Mailing Address - Phone:304-255-6300
Mailing Address - Fax:304-255-6301
Practice Address - Street 1:2401 S KANAWHA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6967
Practice Address - Country:US
Practice Address - Phone:304-255-6300
Practice Address - Fax:304-255-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20964207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014810Medicaid
WV002103799OtherBCBS
WV1059099OtherADVANTRA
WVB614349000OtherFECA/ENERGY
WV7530440OtherAETNA PIN
WV1059099OtherADVANTRA
WV7530440OtherAETNA PIN