Basic Information
| Provider Information | |||||||||
| NPI: | 1497129993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWESTERN MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | NORTHWESTERN PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 FAIRFIELD ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054781726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025245911 | ||||||||
| FaxNumber: | 8025241057 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | ENOSBURG FALLS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054505795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025278189 | ||||||||
| FaxNumber: | 8029338642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | PIGEON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| 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 | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.