Healthcare Provider Details

I. General information

NPI: 1750594529
Provider Name (Legal Business Name): BASSAM N SHAMMA, M.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 MACCORKLE AVE SW STE 301
SOUTH CHARLESTON WV
25309-1364
US

IV. Provider business mailing address

4607 MACCORKLE AVE SW STE 301
SOUTH CHARLESTON WV
25309-1364
US

V. Phone/Fax

Practice location:
  • Phone: 304-767-7919
  • Fax: 304-767-7911
Mailing address:
  • Phone: 304-767-7919
  • Fax: 304-767-7911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16982
License Number StateWV

VIII. Authorized Official

Name: BASSAM N SHAMMA
Title or Position: OWNER
Credential: MD
Phone: 304-767-7919