Provider Demographics
NPI:1982783262
Name:FAYETTE COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:FAYETTE COUNTY BOARD OF HEALTH
Other - Org Name:FAYETTE COUNTY HEALTH DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN,DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:CLIFFORD
Authorized Official - Last Name:NEWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:304-574-1617
Mailing Address - Street 1:202 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1208
Mailing Address - Country:US
Mailing Address - Phone:304-574-1617
Mailing Address - Fax:304-574-1370
Practice Address - Street 1:202 CHURCH ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1208
Practice Address - Country:US
Practice Address - Phone:304-574-1617
Practice Address - Fax:304-574-1370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
WV001251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVFAFV91861Medicare ID - Type Unspecified