Provider Demographics
NPI:1366540833
Name:IBRAHIM-BACHA, GHALI (MD)
Entity type:Individual
Prefix:
First Name:GHALI
Middle Name:
Last Name:IBRAHIM-BACHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 35TH ST SE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1352
Mailing Address - Country:US
Mailing Address - Phone:304-720-9595
Mailing Address - Fax:304-720-9596
Practice Address - Street 1:310 35TH ST SE
Practice Address - Street 2:SUITE 11
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1352
Practice Address - Country:US
Practice Address - Phone:304-720-9595
Practice Address - Fax:304-720-9596
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19464207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0082173000Medicaid
WV0866208Medicare PIN
WVG86504Medicare UPIN