Provider Demographics
NPI:1720055882
Name:FAIRMONT ENT ASSOCIATES INC
Entity Type:Organization
Organization Name:FAIRMONT ENT ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DARISTOTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-366-6157
Mailing Address - Street 1:1712 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-366-6157
Mailing Address - Fax:304-366-0177
Practice Address - Street 1:1712 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-6157
Practice Address - Fax:304-366-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV14772207Y00000X
WV398332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0008704000Medicaid
E46210Medicare UPIN
WV0008704000Medicaid