Provider Demographics
NPI:1609974641
Name:FAIRMONT NEUROLOGY CLINIC, PLLC
Entity type:Organization
Organization Name:FAIRMONT NEUROLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOUHANNAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AZZOUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-598-7000
Mailing Address - Street 1:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:PURSGLOVE
Mailing Address - State:WV
Mailing Address - Zip Code:26546-0333
Mailing Address - Country:US
Mailing Address - Phone:681-285-8755
Mailing Address - Fax:304-825-6577
Practice Address - Street 1:1188 PINEVIEW DR STE 100
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2712
Practice Address - Country:US
Practice Address - Phone:681-285-8755
Practice Address - Fax:304-825-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV204082084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV20408OtherTHE HEALTH PLAN
WV7787352OtherAETNA
WV001721746OtherBLUE CROSS BLUE SHIELD
WV1807858000Medicaid
WV001721746OtherBLUE CROSS BLUE SHIELD
WV1807858000Medicaid