Basic Information
| Provider Information | |||||||||
| NPI: | 1811036783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINDSOR HOSPITAL CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MT ASCUTNEY PHYSICIANS LADIES FIRST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 289 COUNTY RD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050899000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026747300 | ||||||||
| FaxNumber: | 8026747314 | ||||||||
| Practice Location | |||||||||
| Address1: | 289 COUNTY RD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050899000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026747300 | ||||||||
| FaxNumber: | 8026747314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTANIUK | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PROV INS ENROLL COORD | ||||||||
| AuthorizedOfficialTelephone: | 8026747170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINDSOR HOSPITAL CORP | ||||||||
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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 | 8000819 | 05 | VT | MEDICAID |