Provider Demographics
NPI:1871870899
Name:NORTHEASTERN VERMONT REGIONAL HOSPITAL INC
Entity type:Organization
Organization Name:NORTHEASTERN VERMONT REGIONAL HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:HERSEY
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 1:714 BREEZY HILL ROAD
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-0905
Practice Address - Country:US
Practice Address - Phone:805-748-7500
Practice Address - Fax:802-745-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 261QP2300X
VT785261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3076793Medicaid
VT0473991Medicaid
VT1020004Medicaid
VT0473991Medicaid
000451303Medicare PIN