Healthcare Provider Details

I. General information

NPI: 1891755401
Provider Name (Legal Business Name): FAYETTE MEMORIAL HOSPITAL ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3542 WESTERN AVE
CONNERSVILLE IN
47331-3427
US

IV. Provider business mailing address

1941 VIRGINIA AVE
CONNERSVILLE IN
47331-2833
US

V. Phone/Fax

Practice location:
  • Phone: 765-827-8090
  • Fax: 765-827-8093
Mailing address:
  • Phone: 765-827-8933
  • Fax: 765-827-7863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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