Provider Demographics
NPI:1295874436
Name:MOUNTAINEER FAMILY MEDICINE, INC.
Entity type:Organization
Organization Name:MOUNTAINEER FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:SAMAH
Authorized Official - Last Name:KALOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-767-7840
Mailing Address - Street 1:PO BOX 11908
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1908
Mailing Address - Country:US
Mailing Address - Phone:304-767-7840
Mailing Address - Fax:304-767-7849
Practice Address - Street 1:500 POPLAR ST
Practice Address - Street 2:SUITE 204
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1474
Practice Address - Country:US
Practice Address - Phone:304-767-7840
Practice Address - Fax:304-767-7849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010965Medicaid
WV9367011Medicare PIN
WV3810010965Medicaid