Basic Information
| Provider Information | |||||||||
| NPI: | 1366647075 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GHAYTH HAMMAD, MD PSC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 234 W PORTER ST | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422618629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705269652 | ||||||||
| FaxNumber: | 2705269655 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 PORTER ST | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422618629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705269652 | ||||||||
| FaxNumber: | 2705269655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMMAD | ||||||||
| AuthorizedOfficialFirstName: | GHAYTH | ||||||||
| AuthorizedOfficialMiddleName: | MAHMOUD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2705269562 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35218 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 64994130 | 05 | KY | MEDICAID |