MEDICARE: BAYSTATE MARY LANE HOSPITAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center	2148	MA
2	282N00000X	General Acute Care Hospital	2148	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144221847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSTATE MARY LANE HOSPITAL CORPORATION

Provider Business Mailing Address
First Line	:	85 SOUTH ST
Second Line	:
City	:	WARE
State	:	MA
Zip	:	01082-1625
Country	:	US
Telephone Number	:	413-967-6211
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 SOUTH ST
Second Line	:
City	:	WARE
State	:	MA
Zip	:	01082-1625
Country	:	US
Telephone Number	:	413-967-6211
Fax Number	:

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

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	03/11/2014

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Directions to “BAYSTATE MARY LANE HOSPITAL CORPORATION ” Practice Location

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