Provider Demographics
NPI:1518927128
Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC.
Entity Type:Organization
Organization Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC.
Other - Org Name:FAYETTE SALARIED PHYSICIANS
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:765-825-5131
Mailing Address - Street 1:1941 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2833
Mailing Address - Country:US
Mailing Address - Phone:765-825-5131
Mailing Address - Fax:765-827-7863
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:765-827-8933
Practice Address - Fax:765-827-7863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100268220Medicaid
IN100268220Medicaid