Basic Information
Provider Information | |||||||||
NPI: | 1487793352 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WINDSOR HOSPITAL CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MT ASCUTNEY HOSPITAL LADIES FIRST PROGRAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 289 COUNTY RD | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | VT | ||||||||
PostalCode: | 050899000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8026747300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 289 COUNTY RD | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | VT | ||||||||
PostalCode: | 050899000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8026747300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2007 | ||||||||
LastUpdateDate: | 01/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTANIUK | ||||||||
AuthorizedOfficialFirstName: | BONNIE | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PROV INS ENROLL COORD | ||||||||
AuthorizedOfficialTelephone: | 8026747170 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WINDSOR HOSPITAL CORP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 703 | VT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207V00000X | 703 | VT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207R00000X | 703 | VT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8000653 | 05 | VT |   | MEDICAID |