Basic Information
| Provider Information | |||||||||
| NPI: | 1013014489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACKUS | ||||||||
| FirstName: | VERNE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.P.H. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 260 CREST RD, STE 101 | ||||||||
| Address2: | |||||||||
| City: | SWANTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025241223 | ||||||||
| FaxNumber: | 8025241095 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 CREST RD, STE 101 | ||||||||
| Address2: | |||||||||
| City: | SWANTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025241223 | ||||||||
| FaxNumber: | 8025241095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 042-0009809 | VT | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 39665 | 01 | VT | BLUE CROSS PROVIDER NUMBE | OTHER | 5734535 | 01 | VT | CIGNA PROVIDER NUMBER | OTHER | 740518 | 01 | VT | MVP PROVIDER NUMBER | OTHER |