Basic Information
| Provider Information | |||||||||
| NPI: | 1700970829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL AND MEDICAL CENTER OF CUMBERLAND, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN MARYLAND TRAUMA ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 MEMORIAL AVE | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215023765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017234000 | ||||||||
| FaxNumber: | 3017234939 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MEMORIAL AVE | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215023765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017234000 | ||||||||
| FaxNumber: | 3017234939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | W. | ||||||||
| AuthorizedOfficialMiddleName: | GARY | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3017231615 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL HOSPITAL AND MEDICAL CENTER OF CUMBERLAND, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | J536 | 01 | DC | FEDERAL BC BS | OTHER | 0066418000 | 05 | WV | MEDICAID | KEY8TR | 01 | MD | CAREFIRST BC BS | OTHER | C13509 | 01 | MD | TRAVELERS MEDICARE | OTHER |