NPIMap

Organization Active NPI

Princeton Community Hospital Assn., Inc

Doing business as dba Athens Medical Center

  • Family Medicine Physician
  • Athens, WV
National Provider Identifier
1972610863
Registry record updated Dec 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
20079 Issued in WV
Legal business name
PRINCETON COMMUNITY HOSPITAL ASSN., INC
Doing business as
dba Athens Medical Center
Practice address
401 Vermillion St.
Athens, WV 24712
Phone
(304) 384-7325
Fax
(304) 384-8870
NPI assigned
Aug 24, 2006
Last updated
Dec 8, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 8, 2023

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

Authorized official

Name
Mr. Omar R Kassem, MD
Title
Physician
Phone
(304) 384-7325

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 20079 WV Primary

Addresses

Primary practice location

401 Vermillion St.
Athens, WV 24712

Mailing address

PO Box 697
Athens, WV 24712-0697
Phone (304) 384-7325

Other identifiers 1

IdentifierTypeStateIssuer
0034866000MedicaidWV

Other names 1

  • dba Athens Medical Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://www.cms.gov/research-statistics-data-systems/electronic-submission-medical-documentation-esmd/cms-health-information-handler Other CMS HIH

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031216000138 WV Part A Provider - Rural Health Clinic 3678482221 1 other NPI on this enrollment
Practice locations: Athens, WV

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1972610863. Details of each certification follow.

Rural health clinic certification: CCN 513995

Legal name
PRINCETON COMMUNITY HOSPITAL ASSN. INC.
Doing business as
ATHENS MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 6, 1997
Last certification
Mar 10, 2025
Ownership / control type
2B
Organization structure
CorporationProprietary
Incorporated
May 13, 1965 in WV
Enrollment address
401 Vermillion St.
Athens, WV 24712-0697
Related CCNs
510046

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Princeton Communtiy Hos7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

Ownership & related parties

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
James Sarver Individual Corporate OfficerChairman Oct 1, 2015
Amos Mart Lane Individual Corporate OfficerBoard Member Jul 1, 2017
Karen L Bowling Individual Corporate Officer Jul 6, 2021
W-2 Managing Employee Jul 6, 2021
Christopher Daniel Individual Corporate OfficerBoard Member May 1, 2021
David Mullins Individual Corporate Officer Jan 1, 2022
Michael V Webb Individual Corporate OfficerBoard Member Nov 1, 2017
Patty McCormick Individual Corporate OfficerBoard Member Nov 1, 2017
Diane Spencer Individual Corporate Officer Jan 1, 2022
Operational/Managerial Control Jan 1, 2022
Leslie Wellman Individual Corporate OfficerBoard Member Oct 20, 2018
Kevin Martin Individual Corporate OfficerBoard Member Jul 1, 2020
Terry C Graham Individual Corporate OfficerBoard Member Sep 3, 2003
West Virginia United Health System, Inc Organization, Morgantown, WV Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2023 100%
Tamejiro Takubo Individual Corporate Officer Jan 1, 2023
Joe Keatley Individual Corporate OfficerBoard Member Oct 29, 2019
David Graham Individual Corporate OfficerBoard Member Nov 1, 2016
Albert Boland Individual Operational/Managerial ControlVP of Operations Jun 1, 2021

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
PCH Home HealthPrinceton, WV, CCN 517081A Home health agency 5% Or Greater Direct Ownership Interest (33%) May 1, 2007

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 52

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 52

NPI Registry JSON

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

{
    "created_epoch": "1156377600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701993600000",
    "number": "1972610863",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 697",
            "city": "ATHENS",
            "state": "WV",
            "postal_code": "247120697",
            "telephone_number": "304-384-7325",
            "fax_number": "304-384-8870"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 VERMILLION ST.",
            "city": "ATHENS",
            "state": "WV",
            "postal_code": "24712",
            "telephone_number": "304-384-7325",
            "fax_number": "304-384-8870"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRINCETON COMMUNITY HOSPITAL ASSN., INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-24",
        "last_updated": "2023-12-08",
        "certification_date": "2023-12-08",
        "status": "A",
        "authorized_official_last_name": "KASSEM",
        "authorized_official_first_name": "OMAR",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "304-384-7325",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WV",
            "license": "20079",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0034866000",
            "state": "WV"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://www.cms.gov/research-statistics-data-systems/electronic-submission-medical-documentation-esmd/cms-health-information-handler",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.13.34.110.1.998.01",
            "affiliationName": "CMS HIH",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "7500 Security Blvd",
            "city": "Baltimore",
            "state": "MD",
            "country_code": "US",
            "postal_code": "212441849",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "dba Athens Medical Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "dba Athens Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Athens, WV

Sources for this page

Verify at the official NPI Registry.