Provider Demographics
NPI:1144221847
Name:BAYSTATE MARY LANE HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:BAYSTATE MARY LANE HOSPITAL CORPORATION
Other - Org Name:BAYSTATE MARY LANE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE, HEALTHCARE OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHALKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-794-3290
Mailing Address - Street 1:85 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WARE
Mailing Address - State:MA
Mailing Address - Zip Code:01082-1625
Mailing Address - Country:US
Mailing Address - Phone:413-967-6211
Mailing Address - Fax:
Practice Address - Street 1:85 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-1625
Practice Address - Country:US
Practice Address - Phone:413-967-6211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2148261QA0600X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1003674Medicaid
MA1948946Medicaid
MA1201131Medicaid
MA1948946Medicaid