Basic Information
| Provider Information | |||||||||
| NPI: | 1629334164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWESTERN MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | NORTHWESTERN PARTNERS IN HOPE AND RECOVERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 CATHERINE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054782205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025248809 | ||||||||
| FaxNumber: | 8025241250 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 CATHERINE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054782205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025248809 | ||||||||
| FaxNumber: | 8025241289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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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 | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1020281 | 05 | VT | MEDICAID |