Provider Demographics
NPI:1851418230
Name:NORTHERN COUNTIES HEALTH CARE, INC.
Entity Type:Organization
Organization Name:NORTHERN COUNTIES HEALTH CARE, INC.
Other - Org Name:ST. JOHNSBURY COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-748-9405
Mailing Address - Street 1:165 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9811
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:185 SHERMAN DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-5401
Practice Address - Fax:802-748-5094
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN COUNTIES HEALTH CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-23
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0471808Medicaid
VT471808OtherMEDICARE PROVIDER NUMBER
VT471808Medicare Oscar/Certification