NPIMap

Organization Active NPI

Mountaineer Family Medicine, Inc.

  • Family Medicine Physician
  • Charleston, WV
National Provider Identifier
1295874436
Registry record updated Feb 4, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
22493 Issued in WV
Legal business name
MOUNTAINEER FAMILY MEDICINE, INC.
Practice address
500 Poplar St
Suite 204
Charleston, WV 25309-1474
Phone
(304) 767-7840
Fax
(304) 767-7849
NPI assigned
Feb 5, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 4, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mohamad Samah Kalou, MDNPI 1619065190
Title
Owner
Phone
(304) 767-7840

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 22493 WV Primary

Addresses

Primary practice location

500 Poplar St
Suite 204
Charleston, WV 25309-1474

Mailing address

PO Box 11908
Charleston, WV 25339-1908
Phone (304) 767-7840

Other identifiers 1

IdentifierTypeStateIssuer
3810010965MedicaidWV

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070319000427 WV Part B Supplier - Clinic/Group Practice 5496858102 Receives reassigned benefits from 16 practitioners
Practice locations: Nitro, WV; Oceana, WV; Logan, WV; Charleston, WV

National Provider Directory

National Provider Directory
Tax ID family
Mountaineer Family Medicine Inc9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Locations

310 George St
Beckley, WV 25801
Phone (304) 254-9022

258 Hanging Rock Hwy
Ste 2
Logan, WV 25601

500 Poplar St
Ste 204
South Charleston, WV 25309
Phone (304) 414-2895

331 Court St
Welch, WV 24801

Practitioners & affiliated clinicians

Practitioners 19

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 19

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170633600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1202083200000",
    "number": "1295874436",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 11908",
            "city": "CHARLESTON",
            "state": "WV",
            "postal_code": "253391908",
            "telephone_number": "304-767-7840",
            "fax_number": "304-767-7849"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 POPLAR ST",
            "address_2": "SUITE 204",
            "city": "CHARLESTON",
            "state": "WV",
            "postal_code": "253091474",
            "telephone_number": "304-767-7840",
            "fax_number": "304-767-7849"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAINEER FAMILY MEDICINE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-05",
        "last_updated": "2008-02-04",
        "status": "A",
        "authorized_official_last_name": "KALOU",
        "authorized_official_first_name": "MOHAMAD",
        "authorized_official_middle_name": "SAMAH",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "304-767-7840",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "WV",
            "license": "22493",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3810010965",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Charleston, WV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.