Basic Information
| Provider Information | |||||||||
| NPI: | 1962410233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYSTATE WING HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAYSTATE WING HOSPITAL & MEDICAL CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 08/03/2006 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCARTHY | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP, CFO & TREASURER, BH | ||||||||
| AuthorizedOfficialTelephone: | 4137943290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2181 | MA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1001191 | 05 | MA | MEDICAID | 903286 | 01 | TUFTS - OUTPATIENT | OTHER | 2222003085 | 01 | MA | BCBS BEHAVIORAL HLTH | OTHER | 1202057 | 05 | MA | MEDICAID | 2222003010 | 01 | MA | BCBS HOSPITAL OUTPT. | OTHER | 2222003013 | 01 | MA | BCBS MEDICAL CENTERS (OV) | OTHER | 797489 | 01 | NETWORK HEALTH | OTHER | 2222003001 | 01 | MA | BCBS HOSPITAL INPT. | OTHER | 2222003030 | 01 | MA | BCBS OBSERVATION/SDC | OTHER | 903078 | 01 | HARVARD PILGRIM/HOSPITAL | OTHER | 903285 | 01 | TUFTS - HOSPITAL I/P | OTHER |