Provider Demographics
NPI:1518009620
Name:BAYSTATE WING HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:BAYSTATE WING HOSPITAL CORPORATION
Other - Org Name:BAYSTATE WING HOSPITAL: VISITING NURSE ASSOCIATION & HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER & CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:ALLICON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-284-5302
Mailing Address - Street 1:40 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069-1138
Mailing Address - Country:US
Mailing Address - Phone:413-283-9715
Mailing Address - Fax:413-283-8084
Practice Address - Street 1:4 SPRINGFIELD ST., BLDG. 3, 4TH FL.
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MA
Practice Address - Zip Code:01080-1242
Practice Address - Country:US
Practice Address - Phone:413-283-9715
Practice Address - Fax:413-283-8084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYSTATE WING HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2181251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
804993OtherTUFTS HEALTH PLAN
MA221515OtherMA BLUECROSSBLUESHIELD
MA0608157Medicaid
981443OtherNETWORK HEALTH
MA0608157Medicaid