Provider Demographics
NPI:1073582730
Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC.
Entity Type:Organization
Organization Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC.
Other - Org Name:BROOKVILLE IMMEDIATE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-827-7987
Mailing Address - Street 1:1941 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331
Mailing Address - Country:US
Mailing Address - Phone:765-825-5131
Mailing Address - Fax:765-827-7796
Practice Address - Street 1:11137 US HIGHWAY 52 SUITE A
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47012
Practice Address - Country:US
Practice Address - Phone:765-647-5126
Practice Address - Fax:765-647-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050050591261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200061320AMedicaid
OH2320330Medicaid
IN181590Medicare PIN
OH2320330Medicaid