Organization
FAIRMONT NEUROLOGY CLINIC, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MOUHANNAD AZZOUZ MD (OWNER)
(304) 598-7000
Entity
Organization
Contact information
Practice address
1188 PINEVIEW DR STE 100, MORGANTOWN, WV 26505-2712
(681) 285-8755
(304) 825-6577
Mailing address
PO BOX 333, PURSGLOVE, WV 26546-0333
(681) 285-8755
(304) 825-6577
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
WV20408
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001721746
BLUE CROSS BLUE SHIELD
WV
05
—
1807858000
—
WV
01
—
7787352
AETNA
WV
01
—
WV20408
THE HEALTH PLAN
WV
Enumeration date
09/21/2006
Last updated
05/31/2024
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