Provider Demographics
NPI:1639202534
Name:FAYETTE COUNTY MENTAL HEALTH MENTAL RETARDATION PROGRAM
Entity Type:Organization
Organization Name:FAYETTE COUNTY MENTAL HEALTH MENTAL RETARDATION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MDIV
Authorized Official - Phone:724-430-1370
Mailing Address - Street 1:215 JACOB MURPHY LN
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-2777
Mailing Address - Country:US
Mailing Address - Phone:724-430-1370
Mailing Address - Fax:724-430-1386
Practice Address - Street 1:215 JACOB MURPHY LN
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2777
Practice Address - Country:US
Practice Address - Phone:724-430-1370
Practice Address - Fax:724-430-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No251B00000XAgenciesCase Management
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007538290005Medicaid
PA0017040300001Medicaid
PA1007538290004Medicaid
PA1007538290003Medicaid