1851580468 NPI number — FAYETTE CLINIC, PLLC

Table of content: (NPI 1851580468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851580468 NPI number — FAYETTE CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAYETTE CLINIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1851580468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 PHYSICIANS PLAZA
Provider Second Line Business Mailing Address:
PO BOX 130
Provider Business Mailing Address City Name:
LOCHGELLY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-469-3334
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PHYSICIANS PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCHGELLY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-469-3334
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEWELL
Authorized Official First Name:
DARLENE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
304-469-3334

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0206041003 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200164 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0206041000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 513906 . This is a "RURAL HEALTH PROVIDER #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001708474 . This is a "BC/BS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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