Healthcare Provider Details

I. General information

NPI: 1336120047
Provider Name (Legal Business Name): ATHOL MEMORIAL HOSPITAL INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/08/2023
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2033 MAIN STREET
ATHOL MA
01331
US

IV. Provider business mailing address

242 GREEN ST
GARDNER MA
01440-1336
US

V. Phone/Fax

Practice location:
  • Phone: 978-249-3511
  • Fax: 978-249-2651
Mailing address:
  • Phone: 978-632-3420
  • Fax: 978-630-6596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2036
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2036
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2036
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number2036
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number2036
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number2036
License Number StateMA
# 7
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number2226
License Number StateMA
# 8
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number2036
License Number StateMA
# 9
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number050
License Number StateMA
# 10
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number2226
License Number StateMA
# 11
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2036
License Number StateMA
# 12
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2036
License Number StateMA
# 13
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2036
License Number StateMA
# 14
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2036
License Number StateMA

VIII. Authorized Official

Name: THOMAS J SULLIVAN
Title or Position: CEO
Credential:
Phone: 978-630-6157