Healthcare Provider Details

I. General information

NPI: 1326625252
Provider Name (Legal Business Name): FAIRMONT STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/26/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 LOCUST AVE FL 3
FAIRMONT WV
26554-2451
US

IV. Provider business mailing address

1201 LOCUST AVE FL 3
FAIRMONT WV
26554-2451
US

V. Phone/Fax

Practice location:
  • Phone: 304-367-4155
  • Fax:
Mailing address:
  • Phone: 304-367-4155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MIRTA MARTIN
Title or Position: PRESIDENT
Credential: PHD
Phone: 304-367-4151