Basic Information
Provider Information | |||||||||
NPI: | 1245543032 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STEWARD HOLY FAMILY HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOLY FAMILY HOSPITAL PSYCHIATRIC UNIT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 70 EAST ST | ||||||||
Address2: |   | ||||||||
City: | METHUEN | ||||||||
State: | MA | ||||||||
PostalCode: | 018444597 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9786870151 | ||||||||
FaxNumber: | 6175627241 | ||||||||
Practice Location | |||||||||
Address1: | 70 EAST ST | ||||||||
Address2: |   | ||||||||
City: | METHUEN | ||||||||
State: | MA | ||||||||
PostalCode: | 018444597 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9786870151 | ||||||||
FaxNumber: | 6175627241 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2010 | ||||||||
LastUpdateDate: | 11/09/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RENNA | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6174194700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | STEWARD HEALTH CARE SYSTEM LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X |   |   | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 110087057A | 05 | MA |   | MEDICAID |