Provider Demographics
NPI:1417287665
Name:NORTHWESTERN MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:NORTHWESTERN MEDICAL CENTER, INC.
Other - Org Name:NORTHWESTERN MEDICAL CENTER/GEORGIA HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PIGEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-524-8954
Mailing Address - Street 1:133 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-1726
Mailing Address - Country:US
Mailing Address - Phone:802-524-5911
Mailing Address - Fax:802-524-7021
Practice Address - Street 1:4178 HIGHBRIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VT
Practice Address - Zip Code:05454-5446
Practice Address - Country:US
Practice Address - Phone:802-752-1930
Practice Address - Fax:802-524-2867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1017250Medicaid
VT0024685Medicare PIN
VTVT5707Medicare PIN