Provider Demographics
NPI:1417175761
Name:NORTHEAST KINGDOM PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:NORTHEAST KINGDOM PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:802-334-8558
Mailing Address - Street 1:235 LAKEMONT RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-9507
Mailing Address - Country:US
Mailing Address - Phone:802-334-8558
Mailing Address - Fax:802-334-8559
Practice Address - Street 1:235 LAKEMONT RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-9507
Practice Address - Country:US
Practice Address - Phone:802-334-8558
Practice Address - Fax:802-334-8559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009056Medicaid
VT1009056Medicaid