1609974641 NPI number — FAIRMONT NEUROLOGY CLINIC, PLLC

Table of content: (NPI 1609974641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609974641 NPI number — FAIRMONT NEUROLOGY CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRMONT NEUROLOGY 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:
1609974641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 333
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PURSGLOVE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26546-0333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
681-285-8755
Provider Business Mailing Address Fax Number:
304-825-6577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1188 PINEVIEW DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
681-285-8755
Provider Business Practice Location Address Fax Number:
304-825-6577
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AZZOUZ
Authorized Official First Name:
MOUHANNAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-598-7000

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  WV20408 , 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)

  • Identifier: WV20408 . This is a "THE HEALTH PLAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 7787352 . This is a "AETNA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001721746 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1807858000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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