Provider Demographics
NPI:1306849708
Name:BRATTLEBORO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BRATTLEBORO MEMORIAL HOSPITAL
Other - Org Name:BRATTLEBORO MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-257-8203
Mailing Address - Street 1:17 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-3498
Mailing Address - Country:US
Mailing Address - Phone:802-257-0341
Mailing Address - Fax:802-257-8834
Practice Address - Street 1:17 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-3498
Practice Address - Country:US
Practice Address - Phone:802-257-0341
Practice Address - Fax:802-257-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207RC0000X, 207V00000X, 207X00000X, 207Y00000X, 207YX0602X, 208000000X, 208600000X, 208800000X, 282N00000X
VT648282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0470011Medicaid
VT0005692Medicaid
NH3081119Medicaid
VT470011OtherBLUE CROSS PROVIDER #