1235170192 NPI number — MR. MOUSA I DABABNAH M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235170192 NPI number — MR. MOUSA I DABABNAH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DABABNAH
Provider First Name:
MOUSA
Provider Middle Name:
I
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235170192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
856 RITTER DR
Provider Second Line Business Mailing Address:
P.O. BOX 247
Provider Business Mailing Address City Name:
BEAVER
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25813-9513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-255-4845
Provider Business Mailing Address Fax Number:
304-255-4845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
856 RITTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25813-9513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-255-4845
Provider Business Practice Location Address Fax Number:
304-255-4845
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  10670 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8750169013 . This is a "ME" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0134848 . This is a "UMWA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0054813000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 358504041001 . This is a "BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: AS106200 . This is a "PEIA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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