Healthcare Provider Details

I. General information

NPI: 1619973096
Provider Name (Legal Business Name): MICHAEL M BOUSTANY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MOHAMMAD M BOUSTANY MD

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 DIVISION ST
SOUTH CHARLESTON WV
25309
US

IV. Provider business mailing address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-7140
  • Fax: 304-766-7180
Mailing address:
  • Phone: 304-414-4800
  • Fax: 304-414-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number10600
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number10600
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: