Basic Information
| Provider Information | |||||||||
| NPI: | 1053347708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAMFORD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BRENNAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRENNAN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 FISHER RD. | ||||||||
| Address2: | UVM MEDICAL CENTER - FM/BERLIN | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028477000 | ||||||||
| FaxNumber: | 8028477103 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 FISHER RD. | ||||||||
| Address2: | UVM MEDICAL CENTER - FM/BERLIN | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028477000 | ||||||||
| FaxNumber: | 8028477103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD071873L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 042.0013111 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001809031 | 05 | PA | MEDICAID | 039275 | 01 | PA | JOHNS HOPKINS | OTHER | 608838 | 01 | MD | CAREFIRST MD BCBS | OTHER | 01108303 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | 68898 | 01 | PA | GEISINGER | OTHER | 1142446 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER | 110552 | 01 | PA | UNISON-WMG | OTHER | 670422 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 7524489 | 01 | PA | AETNA | OTHER | 284433 | 01 | PA | MAMSI-WMG | OTHER | P002883 | 01 | PA | GATEWAY-WMG | OTHER |