Basic Information
| Provider Information | |||||||||
| NPI: | 1871580811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MERRIMAN HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3073 WHITE MOUNTAIN HWY | ||||||||
| Address2: | |||||||||
| City: | NORTH CONWAY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038607101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033565461 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3073 WHITE MOUNTAIN HWY | ||||||||
| Address2: | |||||||||
| City: | NORTH CONWAY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038605111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033565461 | ||||||||
| FaxNumber: | 6033566033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCLAUGHLIN | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 6033560613 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH0009A | NH | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 3071148 | 05 | NH | MEDICAID |