Healthcare Provider Details

I. General information

NPI: 1003574740
Provider Name (Legal Business Name): NORTHWESTERN MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 FAIRFIELD ST
SAINT ALBANS VT
05478-1726
US

IV. Provider business mailing address

133 FAIRFIELD ST
SAINT ALBANS VT
05478-1726
US

V. Phone/Fax

Practice location:
  • Phone: 802-524-1040
  • Fax: 802-524-1032
Mailing address:
  • Phone: 802-524-5911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DENNIS J BOUCHER
Title or Position: DIRECTOR
Credential:
Phone: 802-524-1276