Provider Demographics
NPI:1073883948
Name:TOWN OF MASSENA
Entity Type:Organization
Organization Name:TOWN OF MASSENA
Other - Org Name:MASSENA MEMORIAL HOSPITAL PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:FAHD
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:315-769-4233
Mailing Address - Street 1:1 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1056
Mailing Address - Country:US
Mailing Address - Phone:315-769-4347
Mailing Address - Fax:315-769-4780
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1056
Practice Address - Country:US
Practice Address - Phone:315-769-4347
Practice Address - Fax:315-769-4780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4402000H282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354398Medicaid
NY70075AMedicare UPIN