Basic Information
| Provider Information | |||||||||
| NPI: | 1003803495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALICE PECK DAY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOONEY | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6034483121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALICE PECK DAY MEMORIAL HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207VX0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 282NC0060X | 00016 | NH | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 30002661 | 05 | NH | MEDICAID | 0009582 | 05 | VT | MEDICAID | 0300016 | 05 | VT | MEDICAID | 80300016 | 05 | NH | MEDICAID |