Provider Demographics
NPI:1568663615
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC
Other - Org Name:LOURDES CENTER FOR ORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PFS
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-584-5459
Mailing Address - Street 1:169 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4246
Mailing Address - Country:US
Mailing Address - Phone:607-584-5459
Mailing Address - Fax:607-584-5482
Practice Address - Street 1:219 FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2424
Practice Address - Country:US
Practice Address - Phone:607-584-4545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0301001H261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0301001HOtherLICENSE NUMBER
NY00337664Medicaid