Provider Demographics
NPI:1902986375
Name:FAYETTE OB/GYN, P.C.
Entity Type:Organization
Organization Name:FAYETTE OB/GYN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-430-6200
Mailing Address - Street 1:404 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-2868
Mailing Address - Country:US
Mailing Address - Phone:724-430-6200
Mailing Address - Fax:724-430-6250
Practice Address - Street 1:404 W MAIN ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2868
Practice Address - Country:US
Practice Address - Phone:724-430-6200
Practice Address - Fax:724-430-6250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015988600001Medicaid
PA1015988600001Medicaid