# FAMILY MEDICAL CLINIC OF JANE LEW (EPSDT)

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1144308040
- **Authorized official:** LILLIE SWISHER (OFFICE MANAGER)
- **Authorized official phone:** (304) 884-7880

## Contact information

- **Practice address:** 134 INDUSTRIAL PARK RD, JANE LEW, WV 26378
- **Practice address phone:** (304) 884-7880
- **Mailing address:** 134 INDUSTRIAL PARK RD, JANE LEW, WV 26378
- **Mailing address phone:** (304) 884-7880

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 11/01/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 5500001000 | — | WV |