Provider Demographics
NPI:1851580468
Name:FAYETTE CLINIC, PLLC
Entity Type:Organization
Organization Name:FAYETTE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:304-469-3334
Mailing Address - Street 1:1 PHYSICIANS PLAZA
Mailing Address - Street 2:PO BOX 130
Mailing Address - City:LOCHGELLY
Mailing Address - State:WV
Mailing Address - Zip Code:25866
Mailing Address - Country:US
Mailing Address - Phone:304-469-3334
Mailing Address - Fax:
Practice Address - Street 1:1 PHYSICIANS PLAZA
Practice Address - Street 2:
Practice Address - City:LOCHGELLY
Practice Address - State:WV
Practice Address - Zip Code:25866
Practice Address - Country:US
Practice Address - Phone:304-469-3334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0206041003Medicaid
WV200164OtherFEDERAL BLACK LUNG
WV0206041000Medicaid
WV513906OtherRURAL HEALTH PROVIDER #
WV001708474OtherBC/BS
WV0206041000Medicaid
WV513906OtherRURAL HEALTH PROVIDER #