Healthcare Provider Details

I. General information

NPI: 1659554046
Provider Name (Legal Business Name): FAIRMONT ENT ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S PRICE ST
KINGWOOD WV
26537-1442
US

IV. Provider business mailing address

1712 LOCUST AVE
FAIRMONT WV
26554-1321
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-6157
  • Fax: 304-366-0177
Mailing address:
  • Phone: 304-366-6157
  • Fax: 304-366-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberWV14772
License Number StateWV

VIII. Authorized Official

Name: DR. JOEDY L DARISTOTLE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 304-366-6157