Community Memorial Hospital
Organization Active NPI Rural Health Clinic/Center · Waterville, NY
NPI 1477080604 · NPPES record last updated Jul 29, 2026
Key facts
- NPI
- 1477080604
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- COMMUNITY MEMORIAL HOSPITAL
- Practice address
- 117 W Main St
Waterville, NY 13480-1165 - Phone
- (315) 841-4184
- NPI assigned
- May 18, 2017
- Organization subpart
- No
Authorized official
- Name
- Tracy Frank
- Title
- Cfo
- Phone
- (315) 824-6550
Owners & managing parties with NPI records 4
-
Ellen M Larson, M.D.
-
Samantha Pulliam, MD
Other NPIs on the same Medicare enrollment 3
Other NPIs with the same Medicare PAC ID 4
Related certifications (CCN) 2
Practitioners 73
-
Melanie R Angell, R, PA-C
-
Kamaljeet Banga, M.D.
-
Scott W Beattie, M.D.
-
Andrew Call, M.D.
-
Lynette Champagne, FNP
-
Robert W Delorme, MD
-
Catherine Docous, PA
-
Martin Ernits, MD
-
Kareem Hamad, MD
-
Abby S Hornyak, RPA-C
-
Jaclyn M Ireland, P.A.
-
Stephen J Jackowski, RPA
-
Linda Keever, NP
-
Nathan E Keever, MD
-
Sherri Lynn Loucks, NP-C
-
Brandy Ann Maciag, FNP
-
Gwen A Manley, F.N.P.
-
Cindy Marshall, FNP
-
Jocelyn Morin, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NY
Rural health clinic certification: CCN 333419
- Legal name
- COMMUNITY MEMORIAL HOSPITAL
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 1, 2022
- Last certification
- Dec 14, 2021
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Oct 10, 1949 in NY
- Enrollment address
- 117 W Main St
Ste 2
Waterville, NY 13480-1165 - Related CCNs
- 331316
All disclosed owners & managing parties 18
| Name | Role | Since | Share |
|---|---|---|---|
| Ellen M Larson |
Corporate Director |
Jun 1, 2023 | |
| Tracy Frank |
Corporate Officer |
Jan 29, 2024 | |
| Operational/Managerial Control |
Jan 1, 2026 | ||
| Samantha J Pulliam |
Corporate Director |
Jun 1, 2025 | |
| Richard Russell |
Corporate Director |
Jun 1, 2023 | |
| Jeffery Coakley |
Corporate Officer |
Dec 1, 2020 | 100% |
| W-2 Managing Employee |
Dec 1, 2020 | 100% | |
| Operational/Managerial Control |
Dec 1, 2020 | 100% | |
| Leigh Baldwin |
Corporate Director |
Jun 1, 2024 | |
| Joanne Borfitz |
Corporate Director |
Jun 1, 2018 | |
| Jeffrey Rubenstein |
Corporate Director |
Jun 1, 2024 | |
| Brooks Cato |
Corporate Director |
Jun 1, 2025 | |
| Mary Brundage |
Corporate Director |
Jun 1, 2019 | |
| Robert Tyburski |
Corporate Director |
Jun 1, 2023 | |
| Bradford G Wheler |
Corporate Officer |
Jun 1, 2022 | |
| Hazel Jack |
Corporate Director |
Jun 1, 2019 | |
| Eve Ann Shwartz |
Corporate Director |
Jun 1, 2025 | |
| Ruthann Loveless |
Corporate Director |
Jun 1, 2024 | |
| Ellen Kraly |
Corporate Director |
Jun 1, 2022 | |
| Richard S Cohen |
Corporate Director |
Jun 1, 2016 | |
| Seth a Kronenberg |
Corporate Director |
Jun 1, 2017 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040714001386 | NY | Part B Supplier - Clinic/Group Practice | 6103805163 |
Receives reassigned benefits from 69 practitioners 3 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Morrisville, NY; Waterville, NY; Munnsville, NY; Hamilton, NY; Cazenovia, NY |
| O20160901001753 | NY | Part a Provider - Rural Health Clinic | 6103805163 |
1 other NPI on this enrollment Practice locations: Waterville, NY |
National Provider Directory
Locations
10 Eaton St
Ste 202
Hamilton, NY 13346
Phone (315) 824-4600
220 Tower St
Waterville, NY 13480
Phone (315) 841-4156
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Adult Medicine Physician |
207QA0505X | |||
| Internal Medicine Physician |
207R00000X | |||
| Primary Care Clinic/Center | 261QP2300X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
117 W Main St
Waterville, NY 13480-1165
Mailing address
150 Broad St
Hamilton, NY 13346-9575
Phone (315) 824-6081
Other providers in Waterville, NY
- Cheryl Marie Blakely
- Svetlana Bykovich
- Michael D Cash
- Francis E Chabot
- Chapman Chiropractic, PLLC
- Nannette S Cowen
- CVS Albany, L.L.C.
- Austin Drake
- James Gilchrist
- Tara Griffin
All providers in Waterville, NY · Rural Health Clinic/Center in New York
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 29, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.