Basic Information
| Provider Information | |||||||||
| NPI: | 1124059035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COUNTRY HOSPITAL & HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RADIOLOGY SERVICES NORTH COUNTRY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 189 PROUTY DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023347331 | ||||||||
| FaxNumber: | 8023343281 | ||||||||
| Practice Location | |||||||||
| Address1: | 189 PROUTY DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023347331 | ||||||||
| FaxNumber: | 8023343281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8023343210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH COUNTRY HOSPITAL & HEALTH CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 33008869 | 01 | VT | BLUE SHIELD | OTHER | 0009721 | 05 | VT | MEDICAID |