Basic Information
Provider Information | |||||||||
NPI: | 1821581174 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWESTERN MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHWESTERN EAR, NOSE & THROAT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 133 FAIRFIELD ST | ||||||||
Address2: |   | ||||||||
City: | SAINT ALBANS | ||||||||
State: | VT | ||||||||
PostalCode: | 054781726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8025248954 | ||||||||
FaxNumber: | 8025241250 | ||||||||
Practice Location | |||||||||
Address1: | 10 CREST RD | ||||||||
Address2: |   | ||||||||
City: | SAINT ALBANS | ||||||||
State: | VT | ||||||||
PostalCode: | 054789701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8025241000 | ||||||||
FaxNumber: | 8025241008 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2018 | ||||||||
LastUpdateDate: | 06/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PIGEON | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 8025248954 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   |
No ID Information.