Provider Demographics
NPI:1295841054
Name:KASSEM, OMAR R (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:R
Last Name:KASSEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-272-9163
Mailing Address - Fax:423-921-6920
Practice Address - Street 1:4307 HIGHWAY 66 S
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3155
Practice Address - Country:US
Practice Address - Phone:423-921-1600
Practice Address - Fax:423-921-6920
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20079207Q00000X
TN14136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0034866000Medicaid
WV513995Medicare Oscar/Certification
WVKA4010581Medicare PIN
F01618Medicare UPIN