Provider Demographics
NPI:1013220805
Name:ADENA FAYETTE MEDICAL CENTER
Entity Type:Organization
Organization Name:ADENA FAYETTE MEDICAL CENTER
Other - Org Name:ADENA HEALTH CENTER - FAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-779-7582
Mailing Address - Street 1:1450 COLUMBUS AVE
Mailing Address - Street 2:SUITE B 6-7-8
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-3701
Mailing Address - Country:US
Mailing Address - Phone:740-333-2236
Mailing Address - Fax:740-333-3881
Practice Address - Street 1:1510 COLUMBUS AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-1899
Practice Address - Country:US
Practice Address - Phone:740-333-3333
Practice Address - Fax:740-333-5171
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAYETTE COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-21
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
363983OtherMEDICARE CCN