Provider Demographics
NPI:1588610570
Name:PRIMARY ONCOLOGY NETWORK PLLC
Entity Type:Organization
Organization Name:PRIMARY ONCOLOGY NETWORK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JURJUS
Authorized Official - Last Name:AZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:304-366-0111
Mailing Address - Street 1:PO BOX 1286
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-1286
Mailing Address - Country:US
Mailing Address - Phone:304-366-0111
Mailing Address - Fax:304-366-2099
Practice Address - Street 1:1325 LOCUST AVE STE 15
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1435
Practice Address - Country:US
Practice Address - Phone:304-366-0111
Practice Address - Fax:304-366-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X
WV17192291U00000X
WV26308332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0204568000Medicaid
WVCH6378OtherRAILROAD MEDICARE
9300761Medicare PIN
WVCH6378OtherRAILROAD MEDICARE
WV3810004204Medicaid
WV1062570001Medicare NSC
WV0204568000Medicaid