Provider Demographics
NPI:1790714228
Name:FAIRMONT PHYSICIANS INC
Entity Type:Organization
Organization Name:FAIRMONT PHYSICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-367-7100
Mailing Address - Street 1:PO BOX 2990
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-367-0043
Mailing Address - Fax:304-367-9470
Practice Address - Street 1:211 MARION SQUARE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-367-0043
Practice Address - Fax:304-367-9470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0009022000Medicaid
WV5922500001Medicare NSC
WV0009022000Medicaid