Basic Information
| Provider Information | |||||||||
| NPI: | 1508825720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1941 VIRGINIA AVENUE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658255131 | ||||||||
| FaxNumber: | 7658277733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473312833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658255131 | ||||||||
| FaxNumber: | 7658277733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2006 | ||||||||
| LastUpdateDate: | 12/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7658255131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 050050591 | IN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100268210A | 05 | IN | MEDICAID | 150064 | 01 | IN | PTAN | OTHER |