Provider Demographics
NPI:1184658007
Name:GHAZALA QUDDUS, M.D., INC.
Entity type:Organization
Organization Name:GHAZALA QUDDUS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-752-3883
Mailing Address - Street 1:167 STOLLINGS AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-4010
Mailing Address - Country:US
Mailing Address - Phone:304-752-8800
Mailing Address - Fax:304-752-9000
Practice Address - Street 1:167 STOLLINGS AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4010
Practice Address - Country:US
Practice Address - Phone:304-752-8800
Practice Address - Fax:304-752-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65920670Medicaid
WV4000440000Medicaid
WV=========005OtherMT STATE BC,BS GROUP #
KY7667Medicare PIN
WV=========005OtherMT STATE BC,BS GROUP #
KY6566Medicare PIN
WV4000440000Medicaid
KY65920670Medicaid