Basic Information
| Provider Information | |||||||||
| NPI: | 1013220805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADENA FAYETTE MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ADENA HEALTH CENTER - FAYETTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 COLUMBUS AVE | ||||||||
| Address2: | SUITE B 6-7-8 | ||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431603701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403332236 | ||||||||
| FaxNumber: | 7403333881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 COLUMBUS AVE | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431601899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403333333 | ||||||||
| FaxNumber: | 7403335171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2010 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7407797582 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAYETTE COUNTY MEMORIAL HOSPITAL | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 363983 | 01 | MEDICARE CCN | OTHER |