Healthcare Provider Details

I. General information

NPI: 1902125883
Provider Name (Legal Business Name): FAYETTE MEMORIAL HOSPITAL ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 VIRGINIA AVE
CONNERSVILLE IN
47331-2833
US

IV. Provider business mailing address

1941 VIRGINIA AVE
CONNERSVILLE IN
47331-2833
US

V. Phone/Fax

Practice location:
  • Phone: 765-827-7704
  • Fax: 765-827-7726
Mailing address:
  • Phone: 765-827-7700
  • Fax: 765-827-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number10-005059-1
License Number StateIN

VIII. Authorized Official

Name: MICHELLE M HENRY
Title or Position: SUPERVISOR PATIENT FINANCIAL SVCS
Credential:
Phone: 765-827-7700