Basic Information
| Provider Information | |||||||||
| NPI: | 1912950643 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARGARETVILLE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAGARETVILLE MEMORIAL HOPSITAL AMBULANCE SQUAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 42084 STATE HIGHWAY 28 | ||||||||
| Address2: | |||||||||
| City: | MARGARETVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124552820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455862631 | ||||||||
| FaxNumber: | 8455862976 | ||||||||
| Practice Location | |||||||||
| Address1: | 42084 STATE HIGHWAY 28 | ||||||||
| Address2: | |||||||||
| City: | MARGARETVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455862631 | ||||||||
| FaxNumber: | 8459436077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 12/31/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POHAR | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8455862631 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 1203 | NY | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 00279387 | 05 | NY | MEDICAID |