Provider Demographics
NPI:1225007982
Name:FAYETTE MEMORIAL HOSPITAL ASSOC
Entity Type:Organization
Organization Name:FAYETTE MEMORIAL HOSPITAL ASSOC
Other - Org Name:UNION COUNTY IMMEDIATE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER AVP
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-827-7709
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:765-827-7762
Mailing Address - Fax:765-827-7796
Practice Address - Street 1:950 MARKET ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:IN
Practice Address - Zip Code:47353
Practice Address - Country:US
Practice Address - Phone:765-458-5191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INOS0050591261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2320358Medicaid
OH2320358Medicaid
IN180120Medicare ID - Type Unspecified