Provider Demographics
NPI:1588800866
Name:FAIRMONT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:FAIRMONT MEDICAL GROUP, INC.
Other - Org Name:SHINNSTON CLINICAL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDERGRIFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-367-8740
Mailing Address - Street 1:PO BOX 1112
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-1112
Mailing Address - Country:US
Mailing Address - Phone:304-367-8710
Mailing Address - Fax:304-366-9529
Practice Address - Street 1:1 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:SHINNSTON
Practice Address - State:WV
Practice Address - Zip Code:26431-1016
Practice Address - Country:US
Practice Address - Phone:304-367-8710
Practice Address - Fax:304-366-8529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRMONT MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV51D0236497OtherCLIA #