Provider Demographics
NPI:1215117262
Name:FAIRMONT GENERAL MDGRP
Entity type:Organization
Organization Name:FAIRMONT GENERAL MDGRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SENGEWALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-367-7152
Mailing Address - Street 1:1325 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1435
Mailing Address - Country:US
Mailing Address - Phone:304-367-7100
Mailing Address - Fax:304-333-2617
Practice Address - Street 1:1325 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1435
Practice Address - Country:US
Practice Address - Phone:304-367-7100
Practice Address - Fax:304-333-2617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV9174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001118003Medicaid