Provider Demographics
NPI:1699809533
Name:NORTHWESTERN MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:NORTHWESTERN MEDICAL CENTER, INC.
Other - Org Name:NORTHWESTERN LIFESTYLE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
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:802-524-1227
Mailing Address - Fax:802-524-8498
Practice Address - Street 1:260 CREST RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9503
Practice Address - Country:US
Practice Address - Phone:802-524-1227
Practice Address - Fax:802-524-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0024685OtherGROUP PTAN