Basic Information
| Provider Information | |||||||||
| NPI: | 1770738262 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WING MEMORIAL HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WING MEMORIAL HOSPITAL & MEDICAL CENTERS/CHIROPRACTIC SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 40 WRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010691138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132837651 | ||||||||
| FaxNumber: | 4132845117 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 WRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010691138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132837651 | ||||||||
| FaxNumber: | 4132845117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2008 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLICON | ||||||||
| AuthorizedOfficialFirstName: | KEARY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4132845302 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WING MEMORIAL HOSPITAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 835 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 2222003013 | 01 | MA | BLUE CROSS OUTPT. MEDICAL CENTERS | OTHER | 0608149 | 05 | MA | MEDICAID | 220030 | 01 | MEDICARE | OTHER | 2222003010 | 01 | MA | BLUE CROSS - HOSPITAL OUTPATIENT | OTHER | 0608157 | 05 | MA | MEDICAID | 1001191 | 05 | MA | MEDICAID | 1202057 | 05 | MA | MEDICAID |