Provider Demographics
NPI:1760655724
Name:FAYETTE SPECIALTY ASSOCIATES
Entity Type:Organization
Organization Name:FAYETTE SPECIALTY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-430-5797
Mailing Address - Street 1:211 EASY ST
Mailing Address - Street 2:SUITE 213
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-3129
Mailing Address - Country:US
Mailing Address - Phone:724-434-1660
Mailing Address - Fax:724-434-1659
Practice Address - Street 1:204 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-2654
Practice Address - Country:US
Practice Address - Phone:724-626-7370
Practice Address - Fax:724-626-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1008468480003Medicaid
PA074222Medicare PIN