Basic Information
| Provider Information | |||||||||
| NPI: | 1619017514 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COUNTRY HOSPITAL & HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY PRACTICE OF NEWPORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 189 PROUTY DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344111 | ||||||||
| FaxNumber: | 8023343281 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344120 | ||||||||
| FaxNumber: | 8023343281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | FOTTER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8023344111 | ||||||||
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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 | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NORT00029083 | 01 | VT | BLUE SHIELD | OTHER | 0VN1031 | 05 | VT | MEDICAID | 8000698 | 01 | VT | LADIES FIRST | OTHER | CA2785 | 01 | VT | RAILROAD MEDICARE | OTHER | 0473980 | 05 | VT | MEDICAID |