Provider Demographics
NPI:1336120047
Name:ATHOL MEMORIAL HOSPITAL INCORPORATED
Entity type:Organization
Organization Name:ATHOL MEMORIAL HOSPITAL INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-630-6157
Mailing Address - Street 1:242 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1336
Mailing Address - Country:US
Mailing Address - Phone:978-632-3420
Mailing Address - Fax:978-630-6596
Practice Address - Street 1:2033 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331
Practice Address - Country:US
Practice Address - Phone:978-249-3511
Practice Address - Fax:978-249-2651
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEYWOOD HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-09
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2036207P00000X, 207Q00000X, 207RC0000X, 2084F0202X, 2084P0805X, 2085B0100X, 282N00000X, 363A00000X, 363L00000X, 363LA2100X, 363LF0000X
MA2226261QM2500X, 282NC0060X
MA050282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110024479BMedicaid
MA1200127Medicaid
MA2222000301OtherBCBS OF MA INPATIENT
MA22Z303OtherMEDICARE SWING BED
MA2222000310OtherBCBS OF MA OUTPATIENT
MA1002244Medicaid
MA22Z303OtherMCRSWING BED
MA110024479CMedicaid
MA1200127Medicaid
MA110024479CMedicaid