Basic Information
| Provider Information | |||||||||
| NPI: | 1962465500 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTHA'S VINEYARD HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MARTHA'S VINEYARD HOSPITAL PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | OAK BLUFFS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025571406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086844500 | ||||||||
| FaxNumber: | 5086844502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | OAK BLUFFS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025571406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086844500 | ||||||||
| FaxNumber: | 5086844502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GANEM | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5086844587 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 208600000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 363L00000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207X00000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208000000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207V00000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 9747231 | 05 | MA | MEDICAID |