Provider Demographics
NPI:1053370270
Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC
Entity type:Organization
Organization Name:FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:450 ERIE AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-3176
Practice Address - Country:US
Practice Address - Phone:765-827-7890
Practice Address - Fax:765-825-6628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-18
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7352421900926323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200406860AMedicaid
IN100415070AMedicaid