Provider Demographics
NPI:1265023170
Name:FAIRWAY MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:FAIRWAY MEDICAL CENTER, LLC
Other - Org Name:AVALA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-801-6258
Mailing Address - Street 1:67252 INDUSTRY LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8704
Mailing Address - Country:US
Mailing Address - Phone:985-809-9888
Mailing Address - Fax:985-801-3099
Practice Address - Street 1:67252 INDUSTRY LN
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8704
Practice Address - Country:US
Practice Address - Phone:985-809-9888
Practice Address - Fax:985-801-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty