Provider Demographics
NPI:1710631635
Name:NORTHEASTERN VERMONT REGIONAL HOSPITAL INC.
Entity Type:Organization
Organization Name:NORTHEASTERN VERMONT REGIONAL HOSPITAL INC.
Other - Org Name:NVRH PODIATRY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:BISSONNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-748-7520
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0905
Mailing Address - Country:US
Mailing Address - Phone:802-748-8141
Mailing Address - Fax:802-748-4098
Practice Address - Street 1:1290 HOSPITAL DR STE 1
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9205
Practice Address - Country:US
Practice Address - Phone:802-748-9400
Practice Address - Fax:802-748-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3136919Medicaid
VT6710925Medicaid