Provider Demographics
NPI:1417390154
Name:FAYETTE MEDICAL SERVICES PLLC
Entity Type:Organization
Organization Name:FAYETTE MEDICAL SERVICES PLLC
Other - Org Name:FAYETTEVILLE URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HAMMACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-574-6900
Mailing Address - Street 1:5447 MAPLE LN STE B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-6872
Mailing Address - Country:US
Mailing Address - Phone:304-574-6900
Mailing Address - Fax:304-574-6922
Practice Address - Street 1:5447 MAPLE LN STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-6872
Practice Address - Country:US
Practice Address - Phone:304-574-6900
Practice Address - Fax:304-574-6922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2487261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care