1336197714 NPI number — OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC

Table of content: (NPI 1336197714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336197714 NPI number — OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC
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:
HOSPICE AT LOURDES
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:
1336197714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4102 OLD VESTAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VESTAL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13850-3531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-798-5692
Provider Business Mailing Address Fax Number:
607-352-1738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4102 OLD VESTAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VESTAL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13850-3531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-798-5692
Provider Business Practice Location Address Fax Number:
607-352-1738
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REGAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP & CFO
Authorized Official Telephone Number:
607-798-5271

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  0301501F , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2105209 . This is a "AETNA PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3300115 . This is a "EMPIRE BC/BS PROVIDER NUM" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 955775 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331505 . This is a "BC/BS OF CENTRAL NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 528113 . This is a "MVP PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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