Provider Demographics
NPI:1801137104
Name:CHARLES F BOU-ABBOUD MD PLLC
Entity type:Organization
Organization Name:CHARLES F BOU-ABBOUD MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOU-ABBOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-252-4900
Mailing Address - Street 1:58 BROOKSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6765
Mailing Address - Country:US
Mailing Address - Phone:304-252-4900
Mailing Address - Fax:304-252-8470
Practice Address - Street 1:58 BROOKSHIRE LN
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6765
Practice Address - Country:US
Practice Address - Phone:304-252-4900
Practice Address - Fax:304-252-8470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16314174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6001170000Medicaid
WV6001170000Medicaid