Provider Demographics
NPI:1073567590
Name:COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.
Other - Org Name:DBA BRANDON MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-855-2083
Mailing Address - Street 1:71 ALLEN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4570
Mailing Address - Country:US
Mailing Address - Phone:800-468-9118
Mailing Address - Fax:802-772-7973
Practice Address - Street 1:420 GROVE ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:VT
Practice Address - Zip Code:05733-9062
Practice Address - Country:US
Practice Address - Phone:802-247-6305
Practice Address - Fax:802-247-6040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0471814Medicaid
NY03044057Medicaid
VT1010852Medicaid
NY03044057Medicaid
VT0471814Medicaid