Healthcare Provider Details

I. General information

NPI: 1073582730
Provider Name (Legal Business Name): FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11137 US HIGHWAY 52 SUITE A
BROOKVILLE IN
47012
US

IV. Provider business mailing address

1941 VIRGINIA AVE
CONNERSVILLE IN
47331
US

V. Phone/Fax

Practice location:
  • Phone: 765-647-5126
  • Fax: 765-647-5900
Mailing address:
  • Phone: 765-825-5131
  • Fax: 765-827-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number050050591
License Number StateIN

VIII. Authorized Official

Name: RANDALL WHITE
Title or Position: CEO
Credential:
Phone: 765-827-7987