Healthcare Provider Details

I. General information

NPI: 1619065190
Provider Name (Legal Business Name): MOHAMAD SAMAH KALOU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5240 MACCORKLE AVE SE
CHARLESTON WV
25304-2122
US

IV. Provider business mailing address

500 POPLAR ST SUITE 204
SOUTH CHARLESTON WV
25309-1474
US

V. Phone/Fax

Practice location:
  • Phone: 304-926-2300
  • Fax: 304-926-2304
Mailing address:
  • Phone: 304-767-7840
  • Fax: 304-767-7849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22493
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.088590
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number22493
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: