Provider Demographics
NPI:1932173218
Name:FAYETTE MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:FAYETTE MEDICAL ASSOCIATES INC
Other - Org Name:THE DOCTORS OFFICE CONNELLSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:PULICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-434-1650
Mailing Address - Street 1:211 EASY ST
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-3129
Mailing Address - Country:US
Mailing Address - Phone:724-434-1650
Mailing Address - Fax:724-434-1659
Practice Address - Street 1:204 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-2654
Practice Address - Country:US
Practice Address - Phone:724-626-7340
Practice Address - Fax:724-626-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA89275OtherUNISON
PA981813OtherHIGHMARK
PA1505529OtherGATEWAY
PA0015441410016Medicaid
PA4024OtherUPMC
PA1505529OtherGATEWAY