Provider Demographics
NPI:1902357940
Name:MARTINSVILLE FAMILY MEDICINE
Entity Type:Organization
Organization Name:MARTINSVILLE FAMILY MEDICINE
Other - Org Name:FAVERO FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:FAVERO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:276-638-7205
Mailing Address - Street 1:2696 GREENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-8106
Mailing Address - Country:US
Mailing Address - Phone:276-638-7205
Mailing Address - Fax:276-638-3389
Practice Address - Street 1:2696 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-8106
Practice Address - Country:US
Practice Address - Phone:276-638-7205
Practice Address - Fax:276-638-3389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173919363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty