Basic Information
| Provider Information | |||||||||
| NPI: | 1043380579 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTE COUNTY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | FAYETTE COUNTY MEMORIAL HOSPITAL MEDICAL AND SURGICAL ASSOCIATES | ||||||||
| 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: | 11/09/2006 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIENER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7403332705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1168 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | 1168 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | 1168 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2970665 | 05 | OH | MEDICAID |