Healthcare Provider Details

I. General information

NPI: 1609216605
Provider Name (Legal Business Name): PEDIATRIC GASTROENTEROLOGY OF CHARLESTON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 DIVISION ST SUITE 3A
SOUTH CHARLESTON WV
25309-1469
US

IV. Provider business mailing address

428 DIVISION ST SUITE 3A
SOUTH CHARLESTON WV
25309-1469
US

V. Phone/Fax

Practice location:
  • Phone: 304-400-4626
  • Fax:
Mailing address:
  • Phone: 304-400-4626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number24418
License Number StateWV

VIII. Authorized Official

Name: DR. AHMED DAHSHAN
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 304-400-4626