Provider Demographics
NPI:1063557189
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT FINANCIAL SERVI
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-584-5459
Mailing Address - Street 1:169 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4246
Mailing Address - Country:US
Mailing Address - Phone:607-584-5459
Mailing Address - Fax:607-584-5482
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-584-5459
Practice Address - Fax:607-584-5482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0301001H207R00000X, 207RP1001X, 207V00000X, 208M00000X, 213E00000X, 363A00000X, 363L00000X, 207Q00000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00903631Medicaid
NY01591419Medicaid
NYCA2906Medicare ID - Type UnspecifiedPALMETTO GBA RAILROAD
NY70050AMedicare ID - Type UnspecifiedPART B PROVIDER #
NY00903631Medicaid