=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326625252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRMONT STATE UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2021
-----------------------------------------------------
Last Update Date | 03/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 LOCUST AVE FL 3
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-367-4155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 LOCUST AVE FL 3
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-367-4155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MIRTA MARTIN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 304-367-4151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1000X
-----------------------------------------------------
Taxonomy Name | Student Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------