Basic Information
| Provider Information | |||||||||
| NPI: | 1366528366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COUNTRY HOSPITAL & HEALTH CENTER INC | ||||||||
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| OtherOrganizationName: | NORTH COUNTRY HEMATOLOGY & ONCOLOGY SERV ICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 189 PROUTY DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023343262 | ||||||||
| FaxNumber: | 8023343223 | ||||||||
| Practice Location | |||||||||
| Address1: | 189 PROUTY DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023343262 | ||||||||
| FaxNumber: | 8023343223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 01/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | FOTTER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8023343271 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 042-0011226 | VT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | DA0586 | 01 | VT | RAILROAD MEDICARE | OTHER | NORT00069769 | 01 | VT | BLUE SHIELD | OTHER | 1008679 | 05 | VT | MEDICAID |