Healthcare Provider Details

I. General information

NPI: 1699371013
Provider Name (Legal Business Name): COMMUNITY MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 S MAIN ST
MUNNSVILLE NY
13409-4058
US

IV. Provider business mailing address

150 BROAD ST
HAMILTON NY
13346-9575
US

V. Phone/Fax

Practice location:
  • Phone: 315-495-2690
  • Fax: 315-495-3915
Mailing address:
  • Phone: 315-824-7088
  • Fax: 315-648-6413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARRIE BOVA
Title or Position: EXECUTIVE DIRECTOR, BUSINESS
Credential:
Phone: 315-824-6560