Basic Information
| Provider Information | |||||||||
| NPI: | 1588800866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRMONT MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHINNSTON CLINICAL LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1112 | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265551112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043678710 | ||||||||
| FaxNumber: | 3043669529 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 COLUMBIA RD | ||||||||
| Address2: | |||||||||
| City: | SHINNSTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 264311016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043678710 | ||||||||
| FaxNumber: | 3043668529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2008 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANDERGRIFT | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043678740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAIRMONT MEDICAL GROUP, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 51D0236497 | 01 | WV | CLIA # | OTHER |