Provider Demographics
NPI:1629087580
Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC.
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEMORIAL HOSPITAL INC.
Other - Org Name:LOURDES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP REVENUE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-584-5492
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:607-798-5111
Mailing Address - Fax:607-798-6730
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-798-5111
Practice Address - Fax:607-798-6730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0301001H282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0301001HOtherSTATE LICENSE
NY00337664Medicaid
NY0301001HOtherSTATE LICENSE
NY00337664Medicaid