Basic Information
| Provider Information | |||||||||
| NPI: | 1073049441 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ATHOL MEMORIAL HOSPITAL INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TULLY FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 242 GREEN ST | ||||||||
| Address2: | ADMIN ANNEX | ||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014401336 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 81 RESERVOIR DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATHOL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782485135 | ||||||||
| FaxNumber: | 9782485130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2017 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | CROSBY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. VP OF FINANCE, CFO | ||||||||
| AuthorizedOfficialTelephone: | 9786306157 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATHOL MEMORIAL HOSPITAL INCORPORATED | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.