Basic Information
| Provider Information | |||||||||
| NPI: | 1831113331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWESTERN VERMONT HEALTH CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | BENNINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 052015004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024426361 | ||||||||
| FaxNumber: | 8024474537 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | BENNINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 052015004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024426361 | ||||||||
| FaxNumber: | 8024474537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 01/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | WICKER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8024426361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | VT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 261QX0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1013238 | 05 | VT | MEDICAID | 0VN1805 | 05 | VT | MEDICAID |