Basic Information
| Provider Information | |||||||||
| NPI: | 1871870899 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEASTERN VERMONT REGIONAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NVRH KINGDOM INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 905 | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058190905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027488141 | ||||||||
| FaxNumber: | 8027484098 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 BREEZY HILL ROAD | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058190905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057487500 | ||||||||
| FaxNumber: | 8027451188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERSEY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8027487520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | 785 | VT | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 3076793 | 05 | NH | MEDICAID | 0473991 | 05 | VT | MEDICAID | 1020004 | 05 | VT | MEDICAID |