Provider Demographics
NPI:1891755401
Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION, INC.
Entity Type:Organization
Organization Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION, INC.
Other - Org Name:PEDIATRIC HEALTH GROUP
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:765-827-7987
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:765-827-8933
Mailing Address - Fax:765-827-7863
Practice Address - Street 1:3542 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-3427
Practice Address - Country:US
Practice Address - Phone:765-827-8090
Practice Address - Fax:765-827-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100115030AMedicaid