Provider Demographics
NPI:1124247127
Name:JEFFERSON PRIMARY CARE
Entity type:Organization
Organization Name:JEFFERSON PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAFA
Authorized Official - Middle Name:MOHAMED
Authorized Official - Last Name:OSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-724-7200
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-0069
Mailing Address - Country:US
Mailing Address - Phone:304-724-7200
Mailing Address - Fax:304-724-7208
Practice Address - Street 1:116 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1641
Practice Address - Country:US
Practice Address - Phone:304-724-7200
Practice Address - Fax:304-724-7208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0101241056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0207571000Medicaid
WV0207571000Medicaid