Basic Information
| Provider Information | |||||||||
| NPI: | 1811241094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC | ||||||||
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| OtherOrganizationName: | SHOREWELL COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 ALLEN ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004689118 | ||||||||
| FaxNumber: | 8027727973 | ||||||||
| Practice Location | |||||||||
| Address1: | 2987 VT ROUTE 22A | ||||||||
| Address2: | |||||||||
| City: | SHOREHAM | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057709728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028977000 | ||||||||
| FaxNumber: | 8028977718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2012 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8028852083 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1021223 | 05 | VT | MEDICAID | 0471844 | 05 | VT | MEDICAID | 03891792 | 05 | NY | MEDICAID |