Athol Memorial Hospital Incorporated
Organization Active NPI Rural Health Clinic/Center · Athol, MA
NPI 1952966491 · NPPES record last updated Jun 8, 2023
Key facts
- NPI
- 1952966491
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- ATHOL MEMORIAL HOSPITAL INCORPORATED
- Practice address
- 2033 Main St
Athol, MA 01331-3535 - Phone
- (978) 249-1295
- Fax
- (978) 249-1550
- NPI assigned
- May 9, 2019
- Organization subpart
- Yes
- Parent organization (as reported)
- ATHOL MEMORIAL HOSPITAL INCORPORATED
Authorized official
- Name
- Thomas J Sullivan
- Title
- Ceo
- Phone
- (978) 630-6157
Owners & managing parties with NPI records 1
-
Elizabeth Nottleson, M.D.
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 2
Related certifications (CCN) 1
Facilities with the same owner 4
Practitioners 81
-
Charles D Allison, MB CHB
-
Christopher Allen Ambler, RN, FNP-BC
-
Magdy Sami Badereldin, MD AND PA
-
Daniel Berman, M.D.
-
Jonas J Berman, MD
-
Jiri Brabec, MD
-
Laura M Chen, MD
-
Ann Cooper, D.O.
-
Maireni R Cruz, MD
-
Erik P. Deede, MD
-
Thomas Dunzendorfer, M.D.
-
Sadie A Eichel, PA
-
Christine Gaggin, NP
-
Chelsea Lee Gagne, FNP-C
-
Kristina Gallant, NP
-
Kevin Michael Hewitt, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 22D2160380 | Athol Primary Care | Certificate of waiver | Jan 8, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MA
Rural health clinic certification: CCN 223980
- Legal name
- ATHOL MEMORIAL HOSPITAL INCORPORATED
- Doing business as
- ATHOL PRIMARY CARE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Apr 15, 2020
- Last certification
- Apr 15, 2020
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 1, 1918 in MA
- Enrollment address
- 2033 Main St
Athol, MA 01331-3535 - Related CCNs
- 221303
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| Craig S Twohey |
Corporate Director |
Feb 1, 2015 | 4.76% |
| Joanne a Parks |
Corporate Director |
Dec 31, 2012 | 4.76% |
| Thomas Sullivan |
Contracted Managing Employee |
Aug 1, 2024 | |
| Corporate Officer |
Feb 5, 2024 | ||
| Corporate Director |
Feb 5, 2024 | ||
| Elizabeth M Nottleson |
Corporate Director |
Dec 1, 2014 | 4.76% |
| Albert S Rose |
Corporate Director |
Jan 25, 2018 | 4.76% |
| John Bujak |
Corporate Officer | Aug 1, 2024 | |
| Corporate Director | Aug 1, 2024 | ||
| W-2 Managing Employee |
Aug 1, 2024 | ||
| Operational/Managerial Control |
Aug 1, 2024 | ||
| Roy V Lake |
Corporate Director |
Dec 31, 2012 | 4.76% |
| Heywood Healthcare Inc |
5% Or Greater Direct Ownership Interest | Dec 1, 2012 | 100% |
| Operational/Managerial Control | Dec 1, 2012 | 100% | |
| Tina M Sbrega |
Corporate Director |
Dec 31, 2012 | 4.76% |
| Cheney M Castine |
Corporate Director |
Dec 31, 2012 | 4.76% |
| Glenn a Hunt |
Corporate Director |
Dec 31, 2012 | 4.76% |
| John M Skrzypczak |
Corporate Director |
Dec 31, 2012 | 4.76% |
| Robert F Chauvin |
Corporate Director |
Dec 31, 2012 | 4.76% |
| Joel R Shaughnessy |
Corporate Director |
Dec 31, 2012 | 4.76% |
| Joyce C Fletcher |
Corporate Director |
Dec 31, 2012 | 4.76% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20190531000142 | MA | Part a Provider - Rural Health Clinic | 7911959846 | Practice locations: Athol, MA |
National Provider Directory
- Tax ID family
- Athol Memorail Hospital
- Part of
- Athol Memorail Hospital
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
2033 Main St
Athol, MA 01331-3535
Mailing address
242 Green St
Gardner, MA 01440-1336
Phone (978) 632-3420
Other names
- Athol Primary Care
Other providers in Athol, MA
- Jeremy Lloyd Askew
- Athol Family Pharmacy Incorporated
- Athol Memorial Hospital Incorporated
- Athol Memorial Hospital Incorporated
- Athol Memorial Hospital Incorporated
- Athol Pharmacy, LLC
- Athol Pharmacy, LLC
- Athol Royalston Regional School District
- Minsub Ban
- Colleen Ada Bannister
All providers in Athol, MA · Rural Health Clinic/Center in Massachusetts
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 8, 2023. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.