1043957970 NPI number — DR. SHADY AHMED HASSANIEN EZALDIN MD

Table of content: DR. SHADY AHMED HASSANIEN EZALDIN MD (NPI 1043957970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043957970 NPI number — DR. SHADY AHMED HASSANIEN EZALDIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EZALDIN
Provider First Name:
SHADY
Provider Middle Name:
AHMED HASSANIEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1043957970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 MACCORKLE AVENUE SOUTHEAST
Provider Second Line Business Mailing Address:
ROBERT C. BIRD CLINICAL TEACHING CENTER, 4TH FLOOR
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-388-5590
Provider Business Mailing Address Fax Number:
304-388-8238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 MACCORKLE AVENUE SOUTHEAST
Provider Second Line Business Practice Location Address:
ROBERT C. BIRD CLINICAL TEACHING CENTER, 4TH FLOOR
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-388-5590
Provider Business Practice Location Address Fax Number:
304-388-8238
Provider Enumeration Date:
05/12/2022

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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