Basic Information
| Provider Information | |||||||||
| NPI: | 1417287665 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWESTERN MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | NORTHWESTERN MEDICAL CENTER/GEORGIA HEALTH CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 FAIRFIELD ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054781726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025245911 | ||||||||
| FaxNumber: | 8025247021 | ||||||||
| Practice Location | |||||||||
| Address1: | 4178 HIGHBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054545446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027521930 | ||||||||
| FaxNumber: | 8025242867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2010 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | PIGEON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8025248954 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1017250 | 05 | VT | MEDICAID |