Provider Demographics
NPI:1508876145
Name:FAYETTE COUNTY HOSPITAL
Entity Type:Organization
Organization Name:FAYETTE COUNTY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-283-1232
Mailing Address - Street 1:650 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1227
Mailing Address - Country:US
Mailing Address - Phone:618-283-1232
Mailing Address - Fax:618-283-1617
Practice Address - Street 1:650 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1227
Practice Address - Country:US
Practice Address - Phone:618-283-1232
Practice Address - Fax:618-283-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000695282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========401Medicaid