Provider Demographics
NPI:1093774275
Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC
Other - Org Name:FAYETTE REGIONAL HEALTH SYSTEM HOME HEALTH
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:765-827-7717
Mailing Address - Fax:765-827-7783
Practice Address - Street 1:1941 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2833
Practice Address - Country:US
Practice Address - Phone:765-825-0046
Practice Address - Fax:765-827-7783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050091491251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100263600AMedicaid
IN157097Medicare PIN
=========013OtherTRICARE
IN=========008OtherBLUE CROSS