1114199411 NPI number — MRS. KIMBERLY J FAIRLEY DO

Table of content: MRS. KIMBERLY J FAIRLEY DO (NPI 1114199411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114199411 NPI number — MRS. KIMBERLY J FAIRLEY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRLEY
Provider First Name:
KIMBERLY
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114199411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
527 MEDICAL PARK DR STE 402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26330-9010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
681-342-3690
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
527 MEDICAL PARK DR STE 402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-9010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
681-342-3690
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  2422 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)