Healthcare Provider Details

I. General information

NPI: 1144221847
Provider Name (Legal Business Name): BAYSTATE MARY LANE HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SOUTH ST
WARE MA
01082-1625
US

IV. Provider business mailing address

85 SOUTH ST
WARE MA
01082-1625
US

V. Phone/Fax

Practice location:
  • Phone: 413-967-6211
  • Fax:
Mailing address:
  • Phone: 413-967-6211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number2148
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number2148
License Number StateMA

VIII. Authorized Official

Name: MR. DENNIS W CHALKE
Title or Position: VP FINANCE, HEALTHCARE OPERATIONS
Credential:
Phone: 413-794-3290