Basic Information
Provider Information
NPI: 1275126260
EntityType: 2
ReplacementNPI:  
OrganizationName: NORTHEASTERN VERMONT REGIONAL HOSPITAL, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: NVRH PULMONOLOGY GROUP
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 905
Address2:  
City: ST JOHNSBURY
State: VT
PostalCode: 058190905
CountryCode: US
TelephoneNumber: 8027488141
FaxNumber: 8027484098
Practice Location
Address1: 1290 HOSPITAL DR, LOWER LEVEL
Address2:  
City: ST. JOHNSBURY
State: VT
PostalCode: 05819
CountryCode: US
TelephoneNumber: 8027456800
FaxNumber: 8027484098
Other Information
ProviderEnumerationDate: 02/19/2021
LastUpdateDate: 12/17/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: HERSEY
AuthorizedOfficialFirstName: ROBERT
AuthorizedOfficialMiddleName: N
AuthorizedOfficialTitleorPosition: CHIEF FINANCIAL OFFICER
AuthorizedOfficialTelephone: 8027487520
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/17/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282NC0060X  N HospitalsGeneral Acute Care HospitalCritical Access
261QM1300X  N Ambulatory Health Care FacilitiesClinic/CenterMulti-Specialty
207RP1001X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease

ID Information
IDTypeStateIssuerDescription
670659705VT MEDICAID
312731205NH MEDICAID


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