Healthcare Provider Details

I. General information

NPI: 1588610570
Provider Name (Legal Business Name): PRIMARY ONCOLOGY NETWORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LOCUST AVE STE 15
FAIRMONT WV
26554-1435
US

IV. Provider business mailing address

PO BOX 1286
FAIRMONT WV
26555-1286
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-0111
  • Fax: 304-366-2099
Mailing address:
  • Phone: 304-366-0111
  • Fax: 304-366-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number17192
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number26308
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN JURJUS AZAR
Title or Position: OWNER
Credential: MD, FACP
Phone: 304-366-0111