Basic Information
| Provider Information | |||||||||
| NPI: | 1457685299 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY HEYWOOD MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEYWOOD HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 242 GREEN ST | ||||||||
| Address2: | |||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014401336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786323420 | ||||||||
| FaxNumber: | 9786306596 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 GREEN ST | ||||||||
| Address2: | |||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014401336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786323420 | ||||||||
| FaxNumber: | 9786306596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2009 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROSBY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9786306157 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH CENTRAL HEALTHCARE, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | 2036 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 273R00000X | 2036 | MA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 1000306 | 05 | MA | MEDICAID | 1200739 | 05 | MA | MEDICAID |