Basic Information
| Provider Information | |||||||||
| NPI: | 1083904213 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF VERMONT MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UVM MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1063 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054021063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028471882 | ||||||||
| FaxNumber: | 8028476254 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028470000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2011 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | VINCENT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8028475911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF VERMONT MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | 748 | VT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
| ID | Type | State | Issuer | Description | 1019123 | 05 | VT | MEDICAID |