Provider Demographics
NPI:1760748693
Name:NORTHWESTERN MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:NORTHWESTERN MEDICAL CENTER, INC.
Other - Org Name:NORTHWESTERN OPHTHALMOLOGY
Other - Org Type:Doing Business As
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 1:128 FISHER POND ROAD, 2ND FLOOR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-4405
Mailing Address - Country:US
Mailing Address - Phone:802-752-1921
Mailing Address - Fax:802-752-1356
Practice Address - Street 1:128 FISHER POND RD, 2ND FLOOR
Practice Address - Street 2:SUITE 3
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-6058
Practice Address - Country:US
Practice Address - Phone:802-752-1921
Practice Address - Fax:802-752-1356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1020384Medicaid
VT1020384Medicaid