Provider Demographics
NPI:1851557284
Name:SUZANNE GHARIB MD PLLC
Entity Type:Organization
Organization Name:SUZANNE GHARIB MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GHARIB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-720-8701
Mailing Address - Street 1:4610 KANAWHA AVENUE SW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-720-8701
Mailing Address - Fax:304-720-8702
Practice Address - Street 1:4610 KANAWHA AVENUE SW
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-720-8701
Practice Address - Fax:304-720-8702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23211207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810012855Medicaid