Basic Information
| Provider Information | |||||||||
| NPI: | 1245226430 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAYETTE MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAYETTE MEDICAL CENTER LTC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 710 | ||||||||
| Address2: | |||||||||
| City: | FAYETTE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355550710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059321112 | ||||||||
| FaxNumber: | 2059321257 | ||||||||
| Practice Location | |||||||||
| Address1: | 1653 TEMPLE AVE N | ||||||||
| Address2: | |||||||||
| City: | FAYETTE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355551314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053438500 | ||||||||
| FaxNumber: | 2059321257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HINDMAN | ||||||||
| AuthorizedOfficialFirstName: | KERI | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2027597378 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | 12539 | AL | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 010124 | 01 | AL | BLUE CROSS | OTHER | 4753120S | 05 | AL | MEDICAID | CG6924 | 01 | AL | RAILROAD MEDICARE | OTHER |