Healthcare Provider Details

I. General information

NPI: 1265512537
Provider Name (Legal Business Name): FAIRMONT MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 LOCUST AVE
FAIRMONT WV
26554
US

IV. Provider business mailing address

1322 LOCUST AVE PO BOX 1112
FAIRMONT WV
26554
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-0700
  • Fax: 304-366-9529
Mailing address:
  • Phone: 304-366-0700
  • Fax: 304-366-9529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NANCY L VANDERGRIFT
Title or Position: PRESIDENT
Credential:
Phone: 304-366-0700