Provider Demographics
NPI:1932100393
Name:COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FADALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-824-6082
Mailing Address - Street 1:150 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346-9575
Mailing Address - Country:US
Mailing Address - Phone:315-824-6082
Mailing Address - Fax:315-824-3182
Practice Address - Street 1:150 BROAD ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-9575
Practice Address - Country:US
Practice Address - Phone:315-824-6082
Practice Address - Fax:315-824-3182
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY331316Medicare Oscar/Certification
70064AMedicare PIN
NY330249Medicare Oscar/Certification