Provider Demographics
NPI:1265485445
Name:MEMORIAL HOSPITAL INC OF TOWANDA PA
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL INC OF TOWANDA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-265-2191
Mailing Address - Street 1:91 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-9702
Mailing Address - Country:US
Mailing Address - Phone:570-265-2191
Mailing Address - Fax:570-265-4797
Practice Address - Street 1:91 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-9702
Practice Address - Country:US
Practice Address - Phone:570-265-2191
Practice Address - Fax:570-265-4797
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL HOSPICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA159899251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007713260018Medicaid
PA391598Medicare ID - Type UnspecifiedHOSPICE