Basic Information
| Provider Information | |||||||||
| NPI: | 1336137702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRVIEW HEALTH ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1029 | ||||||||
| Address2: | |||||||||
| City: | SUMMERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266510139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048725090 | ||||||||
| FaxNumber: | 3048720636 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 FAIRVIEW HEIGHTS RD | ||||||||
| Address2: | |||||||||
| City: | SUMMERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266511085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048725090 | ||||||||
| FaxNumber: | 3048720636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | SHANK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3048725090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0202164000 | 05 | WV | MEDICAID |