NPIMap

Organization Active NPI

Northeastern Vermont Regional Hospital Inc

Doing business as NVRH Kingdom Internal Medicine

  • Rural Health Clinic/Center
  • St Johnsbury, VT
National Provider Identifier
1871870899
Registry record updated Feb 11, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
785 Issued in VT
Legal business name
NORTHEASTERN VERMONT REGIONAL HOSPITAL INC
Doing business as
NVRH Kingdom Internal Medicine
Practice address
714 Breezy Hill Road
St Johnsbury, VT 05819-0905
Phone
(805) 748-7500
Fax
(802) 745-1188
NPI assigned
Nov 4, 2011
Last updated
Feb 11, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert N Hersey
Title
Cfo
Phone
(802) 748-7520

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU
Rural Health Clinic/Center 261QR1300X 785 VT Primary
Internal Medicine Physician 207R00000X NU

Addresses

Primary practice location

714 Breezy Hill Road
St Johnsbury, VT 05819-0905

Mailing address

PO Box 905
St Johnsbury, VT 05819-0905
Phone (802) 748-8141

Other identifiers 3

IdentifierTypeStateIssuer
1020004MedicaidVT
0473991MedicaidVT
3076793MedicaidNH

Other names 1

  • NVRH KINGDOM INTERNAL MEDICINE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VT2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20120306000545 VT Part B Supplier - Clinic/Group Practice 3678481405 Receives reassigned benefits from 10 practitioners
Practice locations: St Johnsbury, VT
O20120628000056 VT Part A Provider - Rural Health Clinic 3678481405 Practice locations: St Johnsbury, VT

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1871870899. Details of each certification follow.

Rural health clinic certification: CCN 473991

Legal name
NORTHEASTERN VERMONT REGIONAL HOSPITAL INC
Doing business as
NVRH KINGDOM INTERNAL MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 10, 2012
Last certification
Oct 10, 2012
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jun 1, 1964 in VT
Enrollment address
714 Breezy Hill Road
St Johnsbury, VT 05819
Related CCNs
471303

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 14

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 14

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
47D2035054NVRH Kingdom Internal Medicine714 Breezy Hill Rd, Saint Johnsbury, VT 05819Certificate of waiverJan 9, 2028

National Provider Directory

National Provider Directory
Tax ID family
NVRH OB GYN13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

Organizations that report the same tax identification number in the National Provider Directory.

Locations

714 Breezy Hill Rd
St Johnsbury, VT 05819
Phone (802) 748-5126

714 Breezy Hill Rd
Ste 1
St Johnsbury, VT 05819
Phone (802) 748-7500

Ownership & related parties

All disclosed owners & managing parties 20

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Sara J Simpson Individual Corporate DirectorSecretary of the Board Dec 3, 2020
Thaddeus R Richardson Individual Corporate DirectorVice Chair of the Board Dec 4, 2019
Joseph S Kasprzak Individual Corporate DirectorTrustee Dec 6, 2016
Lorraine Matteis Individual Corporate DirectorPresident of the Auxiliary Dec 4, 2019
Steve Arthur Feltus Individual Corporate DirectorTrustee Dec 6, 2016
Betsy Bailey Individual Corporate DirectorTrustee Dec 3, 2020
Steven McConnell Individual Corporate DirectorTrustee Apr 26, 2017
Frederic Hoffer Individual Corporate DirectorTrustee Dec 1, 2014
Amanda Felicia Van Straten Individual Corporate DirectorPresident of the Medical Staff Dec 3, 2020
Elaine S Bixby Individual Corporate DirectorTrustee Dec 4, 2021
Warren C Dow Individual Corporate DirectorTrustee Dec 3, 2020
Mary Parent Individual Corporate DirectorChair of the Board Dec 5, 2017
Mark S Bowen Individual Corporate DirectorTrustee Dec 4, 2021
Joshua D Kantrowitz Individual Corporate DirectorPresident Elect(VP) Medical Staff Dec 4, 2021
Natalie B Morris Individual Corporate DirectorTrustee Dec 7, 2022
Peter F Crosby Individual Corporate DirectorTrustee Dec 4, 2021
John S Kascenska Individual Corporate DirectorTrustee Dec 4, 2019
John Goodrich Individual Corporate DirectorTrustee Dec 1, 2015
Andre Bissonnette Individual Corporate OfficerChief Financial Officer Jul 15, 2022
W-2 Managing EmployeeChief Financial Officer Jul 15, 2022
Barbara Hatch Individual Corporate DirectorTrustee Dec 1, 2015

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1320364800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1581379200000",
    "number": "1871870899",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 905",
            "city": "ST JOHNSBURY",
            "state": "VT",
            "postal_code": "058190905",
            "telephone_number": "802-748-8141",
            "fax_number": "802-748-4098"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "714 BREEZY HILL ROAD",
            "city": "ST JOHNSBURY",
            "state": "VT",
            "postal_code": "058190905",
            "telephone_number": "805-748-7500",
            "fax_number": "802-745-1188"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEASTERN VERMONT REGIONAL HOSPITAL INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-11-04",
        "last_updated": "2020-02-11",
        "certification_date": "2020-02-11",
        "status": "A",
        "authorized_official_last_name": "HERSEY",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "N",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "802-748-7520"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "VT",
            "license": "785",
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1020004",
            "state": "VT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0473991",
            "state": "VT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3076793",
            "state": "NH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NVRH KINGDOM INTERNAL MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "NVRH KINGDOM INTERNAL MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in St Johnsbury, VT

Sources for this page

Verify at the official NPI Registry.