Basic Information
| Provider Information | |||||||||
| NPI: | 1952367666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERVAIZ | ||||||||
| FirstName: | NAEEM | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 NEW HOPE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044251522 | ||||||||
| FaxNumber: | 3044879447 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 NEW HOPE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044251522 | ||||||||
| FaxNumber: | 3044879447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 11606 | WV | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 001720055 | 01 | BCBS | OTHER | 0130715000 | 05 | WV | MEDICAID |