Provider Demographics
NPI:1043380579
Name:FAYETTE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:FAYETTE COUNTY MEMORIAL HOSPITAL
Other - Org Name:FAYETTE COUNTY MEMORIAL HOSPITAL MEDICAL AND SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DIENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-333-2705
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1168207Q00000X, 207R00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2970665Medicaid
OH2970665Medicaid