NPIMap

Organization Active NPI

Community Memorial Hospital

  • Rural Health Clinic/Center
  • Waterville, NY
National Provider Identifier
1477080604
Registry record updated Jul 29, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 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
Last updated
Jul 29, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 29, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tracy Frank
Title
Cfo
Phone
(315) 824-6550

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Adult Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207QA0505X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Primary Care Clinic/Center 261QP2300X
Rural Health Clinic/Center 261QR1300X Primary

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1477080604. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Oct 10, 1949 in NY
Enrollment address
117 W Main St
Ste 2
Waterville, NY 13480-1165
Related CCNs
331316

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

10 Eaton St
Ste 202
Hamilton, NY 13346
Phone (315) 824-4600

117 W Main St
#2
Waterville, NY 13480
Phone (315) 841-4184

220 Tower St
Waterville, NY 13480
Phone (315) 841-4156

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Ellen M Larson Individual Corporate DirectorBoard Member Jun 1, 2023
Tracy Frank Individual Corporate OfficerCfo Jan 29, 2024
Operational/Managerial ControlCfo Jan 1, 2026
Samantha J Pulliam Individual Corporate DirectorBoard Member Jun 1, 2025
Richard Russell Individual Corporate DirectorBoard Member Jun 1, 2023
Jeffery Coakley Individual Corporate OfficerPresident/Ceo Dec 1, 2020 100%
W-2 Managing EmployeePresident/Ceo Dec 1, 2020 100%
Operational/Managerial ControlPresident/Ceo Dec 1, 2020 100%
Leigh Baldwin Individual Corporate DirectorBoard Member Jun 1, 2024
Joanne Borfitz Individual Corporate DirectorBoard Member Jun 1, 2018
Jeffrey Rubenstein Individual Corporate DirectorBoard Member Jun 1, 2024
Brooks Cato Individual Corporate DirectorBoard Member Jun 1, 2025
Mary Brundage Individual Corporate DirectorBoard Member Jun 1, 2019
Robert Tyburski Individual Corporate DirectorBoard Member Jun 1, 2023
Bradford G Wheler Individual Corporate OfficerBoard Member Jun 1, 2022
Hazel Jack Individual Corporate DirectorBoard Member Jun 1, 2019
Eve Ann Shwartz Individual Corporate DirectorBoard Member Jun 1, 2025
Ruthann Loveless Individual Corporate DirectorBoard Member Jun 1, 2024
Ellen Kraly Individual Corporate DirectorBoard Member Jun 1, 2022
Richard S Cohen Individual Corporate DirectorBoard Member Jun 1, 2016
Seth a Kronenberg Individual Corporate DirectorBoard Member Jun 1, 2017

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 68

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 68

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1495065600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1785283200000",
    "number": "1477080604",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "150 BROAD ST",
            "city": "HAMILTON",
            "state": "NY",
            "postal_code": "133469575",
            "telephone_number": "315-824-6081"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "117 W MAIN ST",
            "city": "WATERVILLE",
            "state": "NY",
            "postal_code": "134801165",
            "telephone_number": "315-841-4184"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-18",
        "last_updated": "2026-07-29",
        "certification_date": "2026-07-29",
        "status": "A",
        "authorized_official_last_name": "FRANK",
        "authorized_official_first_name": "TRACY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "315-824-6550"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207QA0505X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Adult Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Waterville, NY

Sources for this page

Verify at the official NPI Registry.