Basic Information
Provider Information | |||||||||
NPI: | 1295868008 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH COUNTRY HOSPITAL & HEALTH CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTH COUNTRY OB GYN SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 81 MEDICAL VILLAGE DR | ||||||||
Address2: | SUITE 2 | ||||||||
City: | NEWPORT | ||||||||
State: | VT | ||||||||
PostalCode: | 058559836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8023344110 | ||||||||
FaxNumber: | 8023344113 | ||||||||
Practice Location | |||||||||
Address1: | 189 PROUTY DR | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | VT | ||||||||
PostalCode: | 058559326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8023344111 | ||||||||
FaxNumber: | 8023343281 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2007 | ||||||||
LastUpdateDate: | 08/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOTTER | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8023343271 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 015608544 | 01 | VT | HARVARD PILGRAM HEALTH PL | OTHER | 0473982 | 05 | VT |   | MEDICAID | OVN0584 | 05 | VT |   | MEDICAID | 101315300 | 01 | VT | DEPT OF LABOR WORKERS COM | OTHER | NORT00029083 | 01 | VT | BLUE SHIELD OF VERMONT | OTHER | 30008005 | 05 | NH |   | MEDICAID | 8000747 | 01 | VT | LADIES FIRST DEPT OF HEAL | OTHER | CG5262 | 01 | VT | RAILROAD MEDICARE | OTHER |