Basic Information
| Provider Information | |||||||||
| NPI: | 1053532259 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLON & RECTAL CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6855 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260030923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042339314 | ||||||||
| FaxNumber: | 3042330265 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 MEDICAL PARK | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260036392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0000000000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KALLA | ||||||||
| AuthorizedOfficialFirstName: | AHMED | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3042339314 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.