1013220805 NPI number — ADENA FAYETTE MEDICAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013220805 NPI number — ADENA FAYETTE MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADENA FAYETTE MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADENA HEALTH CENTER - FAYETTE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013220805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 COLUMBUS AVE
Provider Second Line Business Mailing Address:
SUITE B 6-7-8
Provider Business Mailing Address City Name:
WASHINGTON COURT HOUSE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43160-3701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-333-2236
Provider Business Mailing Address Fax Number:
740-333-3881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 COLUMBUS AVE
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
WASHINGTON COURT HOUSE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43160-1899
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-333-3333
Provider Business Practice Location Address Fax Number:
740-333-5171
Provider Enumeration Date:
07/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
LISA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
740-779-7582

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 363983 . This is a "MEDICARE CCN" identifier . This identifiers is of the category "OTHER".




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