Provider Demographics
NPI:1437184462
Name:MARY LOU FRAGILE DO
Entity Type:Organization
Organization Name:MARY LOU FRAGILE DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO FAMILY PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGILE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-647-3331
Mailing Address - Street 1:PO BOX 1788
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-647-3331
Mailing Address - Fax:304-647-9799
Practice Address - Street 1:RR 2 BOX 171C
Practice Address - Street 2:GREYROCK PROF PARK
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-647-3331
Practice Address - Fax:304-647-9799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2003958000Medicaid
WV2003958000Medicaid
H77291Medicare UPIN