MEDICARE: NORTHWESTERN MEDICAL CENTER, 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	207LP2900X	Pain Medicine (Anesthesiology) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629334164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWESTERN MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	17 CATHERINE ST
Second Line	:
City	:	SAINT ALBANS
State	:	VT
Zip	:	05478-2205
Country	:	US
Telephone Number	:	802-524-8809
Fax Number	:	802-524-1250

Provider Business Practice Location Address
First Line	:	17 CATHERINE ST
Second Line	:
City	:	SAINT ALBANS
State	:	VT
Zip	:	05478-2205
Country	:	US
Telephone Number	:	802-524-8809
Fax Number	:	802-524-1289

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

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	07/10/2019

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