Provider Demographics
NPI:1740599919
Name:AMJAD MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:AMJAD MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QUARTEL-AYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:AMJAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-252-5900
Mailing Address - Street 1:330 N EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-252-5900
Mailing Address - Fax:604-252-5915
Practice Address - Street 1:330 N EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-252-5900
Practice Address - Fax:604-252-5915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
WV24182261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV24182OtherWV MEDICAL LICENSE
WV3810019138Medicaid