Basic Information
| Provider Information | |||||||||
| NPI: | 1518927128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC. | ||||||||
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| OtherOrganizationName: | FAYETTE SALARIED PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1941 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473312833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658255131 | ||||||||
| FaxNumber: | 7658277863 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473312833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658278933 | ||||||||
| FaxNumber: | 7658277863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 04/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7658255131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207ZP0105X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 100268220 | 05 | IN | MEDICAID |