Basic Information
| Provider Information | |||||||||
| NPI: | 1508835216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAYETTE REGIONAL HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1941 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473312833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658278933 | ||||||||
| FaxNumber: | 7658277863 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473312833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658277900 | ||||||||
| FaxNumber: | 7658277907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7658277987 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 050050591 | IN | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 100268210A | 05 | IN | MEDICAID |