Healthcare Provider Details

I. General information

NPI: 1760691596
Provider Name (Legal Business Name): LOGAN GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 WOODCREST LN
CHARLESTON WV
25314-2472
US

IV. Provider business mailing address

77 HOSPITAL DR
LOGAN WV
25601-3451
US

V. Phone/Fax

Practice location:
  • Phone: 304-792-1122
  • Fax:
Mailing address:
  • Phone: 304-792-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: BASSAM HAFFAR
Title or Position: OWNER
Credential: MD
Phone: 304-792-1122