=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689854929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMAR HALLAK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2007
-----------------------------------------------------
Last Update Date | 11/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 LAIDLEY ST SUITE 402
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25301-1619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-345-2090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 331 LAIDLEY ST SUITE 402
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25301-1619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-345-2090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 19813
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------