MEDICARE: COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	471816	OTHER	VT	NAT'L GOV SERVICES
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104870922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.

Provider Business Mailing Address
First Line	:	71 ALLEN ST
Second Line	:	SUITE 403
City	:	RUTLAND
State	:	VT
Zip	:	05701-4570
Country	:	US
Telephone Number	:	802-772-4414
Fax Number	:	802-772-7973

Provider Business Practice Location Address
First Line	:	278 VT ROUTE 149
Second Line	:
City	:	WEST PAWLET
State	:	VT
Zip	:	05775-9798
Country	:	US
Telephone Number	:	802-645-0580
Fax Number	:	802-645-0587

Authorized Official
Title or Position	:	FINANCE DIRECTOR
Name	:	MICHAEL L GARDNER
Credential	:
Telephone Number	:	802-855-2080

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	09/11/2018

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