Healthcare Provider Details

I. General information

NPI: 1003900283
Provider Name (Legal Business Name): SAAD MOSSALLATI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 MEDICAL PARK DRIVE SUITE 204
BRIDGEPORT WV
26330
US

IV. Provider business mailing address

527 MEDICAL PARK DRIVE SUITE 204
BRIDGEPORT WV
26330
US

V. Phone/Fax

Practice location:
  • Phone: 304-933-3800
  • Fax: 304-933-3815
Mailing address:
  • Phone: 304-933-3800
  • Fax: 304-933-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberWV13308
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: