Provider Demographics
NPI:1356368104
Name:FAYETTE COUNTY GOVERNMENT
Entity type:Organization
Organization Name:FAYETTE COUNTY GOVERNMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAYETTE COUNTY HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:B
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-825-0511
Mailing Address - Street 1:401 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331
Mailing Address - Country:US
Mailing Address - Phone:765-825-4013
Mailing Address - Fax:765-825-7189
Practice Address - Street 1:401 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331
Practice Address - Country:US
Practice Address - Phone:765-825-4013
Practice Address - Fax:765-825-7189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
TA6030Medicare ID - Type Unspecified