Provider Demographics
NPI:1295852549
Name:NORTHERN COUNTIES HEALTH CARE, INC.
Entity Type:Organization
Organization Name:NORTHERN COUNTIES HEALTH CARE, INC.
Other - Org Name:CONCORD HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-748-9405
Mailing Address - Street 1:165 SHERMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:185 SHERMAN DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9811
Practice Address - Country:US
Practice Address - Phone:802-695-2512
Practice Address - Fax:802-695-1303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT471801OtherMEDICARE PROVIDER NUMBER
VT0473807Medicaid
VT471801Medicare Oscar/Certification