Basic Information
| Provider Information | |||||||||
| NPI: | 1831491042 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MVA X-RAY FAIRMONT CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1322 LOCUST AVE | ||||||||
| Address2: | PO BOX 1112 | ||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265541436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043678740 | ||||||||
| FaxNumber: | 3043669529 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322 LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265541436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043678740 | ||||||||
| FaxNumber: | 3043669529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2010 | ||||||||
| LastUpdateDate: | 09/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | VANDERGRIFT | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043678740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONONGAHELA VALLEY ASSOCIATION OF HEALTH CENTERS, INC. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 1034-6686 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0121537000 | 05 | WV | MEDICAID |