Basic Information
| Provider Information | |||||||||
| NPI: | 1972634889 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH COUNTRY HOSPITAL & HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH COUNTRY NEUROLOGY 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: | 03/09/2007 | ||||||||
| LastUpdateDate: | 01/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | FOTTER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8023344111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 30214523 | 05 | NH | MEDICAID | CI3697 | 01 | VT | RAILROAD MEDICARE | OTHER | 0572880002 | 01 | VT | DME | OTHER | NORT00019682 | 01 | VT | BLUE SHIELD | OTHER | 13842 | 01 | VT | MVP | OTHER | OVN0871 | 05 | VT | MEDICAID |