Organization
FAIRMONT ENT ASSOCIATES, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOEDY L DARISTOTLE M.D. (PHYSICIAN)
(304) 366-6157
Entity
Organization
Contact information
Practice address
300 S PRICE ST, KINGWOOD, WV 26537-1442
(304) 366-6157
(304) 366-0177
Mailing address
1712 LOCUST AVE, FAIRMONT, WV 26554-1321
(304) 366-6157
(304) 366-0177
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
WV14772
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0041418000
—
WV
01
—
CL6325
RR MEDICARE
WV
Enumeration date
12/10/2007
Last updated
05/22/2008
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