Basic Information
| Provider Information | |||||||||
| NPI: | 1508413725 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTHA'S VINEYARD HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARTHA'S VINEYARD HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1477 | ||||||||
| Address2: | |||||||||
| City: | OAK BLUFFS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025571477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086930410 | ||||||||
| FaxNumber: | 5086967746 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | OAK BLUFFS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025571406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086930410 | ||||||||
| FaxNumber: | 5086967746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2019 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GANEM | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5086844587 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.