1063546984 NPI number — NORTHWESTERN MEDICAL CENTER, INC.

Table of content: (NPI 1063546984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063546984 NPI number — NORTHWESTERN MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWESTERN MEDICAL CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHWESTERN PATHOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063546984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
133 FAIRFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT ALBANS
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05478-1726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-524-5911
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 FAIRFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ALBANS
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05478-1726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-524-1074
Provider Business Practice Location Address Fax Number:
802-524-1098
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PIGEON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
802-524-8954

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  690 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: VT5814 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: C26350 . This is a "RR TRAVELERS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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