Provider Demographics
NPI:1881895100
Name:APPALACHIAN GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:APPALACHIAN GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUSAM
Authorized Official - Middle Name:MOHAMMAD
Authorized Official - Last Name:NAZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FACP,FACG
Authorized Official - Phone:304-253-0849
Mailing Address - Street 1:P.O. BOX 1189
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802
Mailing Address - Country:US
Mailing Address - Phone:304-253-0849
Mailing Address - Fax:304-253-1573
Practice Address - Street 1:429 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-253-0849
Practice Address - Fax:304-253-1573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13335302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0071942000Medicaid
WV0071942000Medicaid
WVB28463Medicare UPIN