Basic Information
| Provider Information | |||||||||
| NPI: | 1669437216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL AND MEDICAL CENTER OF CUMBERLAND, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL HOSP MED CTR HOSP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 600 MEMORIAL AVE | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215023765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017234000 | ||||||||
| FaxNumber: | 3017231480 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MEMORIAL AVE | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215023765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017234000 | ||||||||
| FaxNumber: | 3017231480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REPAC | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 3017236414 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 01-006 | MD | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 217125 | 01 | MD | ALLIANCE MAMSI MDIPA OPC | OTHER | MB4 | 01 | MD | BLUE CHOICE FEDERAL | OTHER | 0001768000 | 05 | WV | MEDICAID | 1007410690004 | 05 | PA | MEDICAID | 59010201 | 01 | MD | BLUE CROSS | OTHER |