Provider Demographics
NPI:1811922362
Name:FAW, MARY ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:FAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1320
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-1320
Mailing Address - Country:US
Mailing Address - Phone:304-388-1724
Mailing Address - Fax:304-388-1721
Practice Address - Street 1:3825 TEAYS VALLEY ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526
Practice Address - Country:US
Practice Address - Phone:304-757-0050
Practice Address - Fax:304-757-0061
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20376207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001723914OtherBLUE CROSS BLUE SHIELD
WV753146655OtherP.E.I.A./ACORDIA
WV001723915OtherBLUE CROSS BLUE SHIELD
WV753146655OtherF.E.I.N.
P01050843OtherRAILROAD
WV3005015-000Medicaid
WV7560573OtherAETNA
WV753146655OtherP.E.I.A./ACORDIA
WVWV1292AMedicare PIN
WVFA4122402Medicare ID - Type Unspecified