Healthcare Provider Details

I. General information

NPI: 1225007982
Provider Name (Legal Business Name): FAYETTE MEMORIAL HOSPITAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 MARKET ST
LIBERTY IN
47353
US

IV. Provider business mailing address

1941 VIRGINIA AVE
CONNERSVILLE IN
47331
US

V. Phone/Fax

Practice location:
  • Phone: 765-458-5191
  • Fax:
Mailing address:
  • Phone: 765-827-7762
  • Fax: 765-827-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberOS0050591
License Number StateIN

VIII. Authorized Official

Name: MRS. MARILYN M THOMPSON
Title or Position: CONTROLLER AVP
Credential:
Phone: 765-827-7709