Provider Demographics
NPI:1225169733
Name:FAIRWAY PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:FAIRWAY PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KIFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-942-9494
Mailing Address - Street 1:2950 FAIRWAY DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-4457
Mailing Address - Country:US
Mailing Address - Phone:814-942-9494
Mailing Address - Fax:814-942-4399
Practice Address - Street 1:2950 FAIRWAY DR
Practice Address - Street 2:SUITE 2
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4457
Practice Address - Country:US
Practice Address - Phone:814-942-9494
Practice Address - Fax:814-942-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010770L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADB9443OtherRAILROAD MEDICARE
PA071450Medicare PIN