Provider Demographics
NPI:1972682748
Name:FAYETTE CO PHYSICIAN ORGANIZATION DBA FAMILY PRACTICE WVMC
Entity Type:Organization
Organization Name:FAYETTE CO PHYSICIAN ORGANIZATION DBA FAMILY PRACTICE WVMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-827-1903
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-0779
Mailing Address - Country:US
Mailing Address - Phone:765-825-8686
Mailing Address - Fax:765-827-1918
Practice Address - Street 1:1473 E STATE ROAD 44
Practice Address - Street 2:SUITE 2
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-8292
Practice Address - Country:US
Practice Address - Phone:765-825-8686
Practice Address - Fax:765-827-1918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
251590Medicare PIN