Healthcare Provider Details

I. General information

NPI: 1518009273
Provider Name (Legal Business Name): BAYSTATE WING HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SPRINGFIELD ST., BLDG. 3, 4TH FL.
THREE RIVERS MA
01080-1242
US

IV. Provider business mailing address

40 WRIGHT ST
PALMER MA
01069-1138
US

V. Phone/Fax

Practice location:
  • Phone: 413-283-9715
  • Fax: 413-283-8084
Mailing address:
  • Phone: 413-283-9715
  • Fax: 413-283-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number2181
License Number StateMA

VIII. Authorized Official

Name: KEARY T ALLICON
Title or Position: TREASURER & CFO
Credential:
Phone: 413-284-5302