Provider Demographics
NPI:1336197714
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:SR VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-798-5271
Mailing Address - Street 1:4102 OLD VESTAL RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3531
Mailing Address - Country:US
Mailing Address - Phone:607-798-5692
Mailing Address - Fax:607-352-1738
Practice Address - Street 1:4102 OLD VESTAL RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3531
Practice Address - Country:US
Practice Address - Phone:607-798-5692
Practice Address - Fax:607-352-1738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0301501F251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
2105209OtherAETNA PROVIDER NUMBER
NY3300115OtherEMPIRE BC/BS PROVIDER NUM
NY955775Medicaid
NY331505OtherBC/BS OF CENTRAL NY
NY528113OtherMVP PROVIDER NUMBER
NY955775Medicaid