1689808925 NPI number — RALEIGH LUNG CLINIC INCORPORATED PC

Table of content: AMBRIA LILES MS (NPI 1124534631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689808925 NPI number — RALEIGH LUNG CLINIC INCORPORATED PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RALEIGH LUNG CLINIC INCORPORATED PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1689808925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 FOX SPARROW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BECKLEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25801-3687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-255-6300
Provider Business Mailing Address Fax Number:
304-255-6301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 S KANAWHA ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BECKLEY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25801-6967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-255-6300
Provider Business Practice Location Address Fax Number:
304-255-6301
Provider Enumeration Date:
05/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HADDADIN
Authorized Official First Name:
RAMZI
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-255-6300

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  20964 , 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: 3810014810 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002103799 . This is a "BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1059099 . This is a "ADVANTRA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: B614349000 . This is a "FECA/ENERGY" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 7530440 . This is a "AETNA PIN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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