Healthcare Provider Details

I. General information

NPI: 1376644625
Provider Name (Legal Business Name): ROBERT J FANNING, JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 MOUNT DE CHANTAL RD
WHEELING WV
26003-6334
US

IV. Provider business mailing address

1307 MOUNT DE CHANTAL RD
WHEELING WV
26003-6334
US

V. Phone/Fax

Practice location:
  • Phone: 304-242-1273
  • Fax: 304-242-1422
Mailing address:
  • Phone: 304-242-1273
  • Fax: 304-242-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number46155
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1431
License Number StateWV

VIII. Authorized Official

Name: DR. ROBERT J FANNING JR.
Title or Position: CARDIOLOGIST
Credential: DO
Phone: 304-242-1273