Basic Information
| Provider Information | |||||||||
| NPI: | 1972634350 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH COUNTRY HOSPITAL & HEALTH SYSTEMS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH COUNTRY UROLOGY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 189 PROUTY DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344111 | ||||||||
| FaxNumber: | 8023343281 | ||||||||
| Practice Location | |||||||||
| Address1: | 189 PROUTY DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344111 | ||||||||
| FaxNumber: | 8023343281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 04/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | BISSONNETT | ||||||||
| AuthorizedOfficialFirstName: | ANDRE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8023344111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 332B00000X | 042-0010304 | VT | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30201717 | 05 | NH | MEDICAID | NORT00058438 | 01 | VT | BLUE SHIELD | OTHER | NORT00058665 | 01 | VT | BLUE SHIELD | OTHER | 1009352 | 05 | VT | MEDICAID | 1008679 | 05 | VT | MEDICAID | CA2785 | 01 | VT | RAILROAD MEDICARE | OTHER |