Provider Demographics
NPI:1851556237
Name:FAYETTE COUNTY
Entity Type:Organization
Organization Name:FAYETTE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-283-1044
Mailing Address - Street 1:416 W EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-2706
Mailing Address - Country:US
Mailing Address - Phone:618-283-7262
Mailing Address - Fax:618-283-5039
Practice Address - Street 1:416 W EDWARDS ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-2706
Practice Address - Country:US
Practice Address - Phone:618-283-7262
Practice Address - Fax:618-283-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2017-02-02
Deactivation Date:2008-09-08
Deactivation Code:
Reactivation Date:2009-04-28
Provider Licenses
StateLicense IDTaxonomies
IL1863108251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL141607Medicare PIN