Healthcare Provider Details

I. General information

NPI: 1114915899
Provider Name (Legal Business Name): SHABAN AL SHOSHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WELDAY AVE
WINTERSVILLE OH
43953-3779
US

IV. Provider business mailing address

651 COLLIERS WAY STE 300
WEIRTON WV
26062-5058
US

V. Phone/Fax

Practice location:
  • Phone: 740-266-8004
  • Fax: 740-266-8005
Mailing address:
  • Phone: 304-797-6404
  • Fax: 304-797-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35073795
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: