Provider Demographics
NPI:1104889971
Name:FAIRMONT EYE CARE INC
Entity type:Organization
Organization Name:FAIRMONT EYE CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:WILMOTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-366-4721
Mailing Address - Street 1:709 MORGANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4331
Mailing Address - Country:US
Mailing Address - Phone:304-366-4721
Mailing Address - Fax:304-366-4847
Practice Address - Street 1:709 MORGANTOWN AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-4721
Practice Address - Fax:304-366-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV015096400Medicaid
WVCM3317OtherRAILROAD MEDICARE
WVFA9263131Medicare ID - Type UnspecifiedGROUP
WV0154150001Medicare NSC