Basic Information
| Provider Information | |||||||||
| NPI: | 1629087580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OUR LADY OF LOURDES MEMORIAL HOSPITAL INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LOURDES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077985111 | ||||||||
| FaxNumber: | 6077986730 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077985111 | ||||||||
| FaxNumber: | 6077986730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANNE | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AVP REVENUE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6075845492 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0301001H | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0301001H | 01 | NY | STATE LICENSE | OTHER | 00337664 | 05 | NY | MEDICAID |