Provider Demographics
NPI:1962465500
Name:MARTHA'S VINEYARD HOSPITAL
Entity type:Organization
Organization Name:MARTHA'S VINEYARD HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:GANEM
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:508-684-4587
Mailing Address - Street 1:1 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557-1406
Mailing Address - Country:US
Mailing Address - Phone:508-684-4500
Mailing Address - Fax:508-684-4502
Practice Address - Street 1:1 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557-1406
Practice Address - Country:US
Practice Address - Phone:508-684-4500
Practice Address - Fax:508-684-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207V00000X, 207X00000X, 208000000X, 208600000X, 363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9747231Medicaid
MAM21826Medicare PIN