Provider Demographics
NPI:1659554046
Name:FAIRMONT ENT ASSOCIATES, INC.
Entity Type:Organization
Organization Name:FAIRMONT ENT ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DARISTOTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-366-6157
Mailing Address - Street 1:1712 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1321
Mailing Address - Country:US
Mailing Address - Phone:304-366-6157
Mailing Address - Fax:304-366-0177
Practice Address - Street 1:300 S PRICE ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1442
Practice Address - Country:US
Practice Address - Phone:304-366-6157
Practice Address - Fax:304-366-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV14772261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0041418000Medicaid
WVCL6325OtherRR MEDICARE
WVCL6325OtherRR MEDICARE
WVE46210Medicare UPIN