Basic Information
Provider Information | |||||||||
NPI: | 1972610863 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRINCETON COMMUNITY HOSPITAL ASSN., INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DBA ATHENS MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 697 | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | WV | ||||||||
PostalCode: | 247120697 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043847325 | ||||||||
FaxNumber: | 3043848870 | ||||||||
Practice Location | |||||||||
Address1: | 401 VERMILLION ST. | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | WV | ||||||||
PostalCode: | 24712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043847325 | ||||||||
FaxNumber: | 3043848870 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 08/04/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KASSEM | ||||||||
AuthorizedOfficialFirstName: | OMAR | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 3043847325 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20079 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0034866000 | 05 | WV |   | MEDICAID |