Healthcare Provider Details

I. General information

NPI: 1821784711
Provider Name (Legal Business Name): HEBAH SOUDAN MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 205
CHARLESTON WV
25304-1228
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE STE 205
CHARLESTON WV
25304-1228
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2303
  • Fax: 304-388-2390
Mailing address:
  • Phone: 304-388-2303
  • Fax: 304-388-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number57.255215
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: