Basic Information
Provider Information | |||||||||
NPI: | 1194807040 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUCHANAN | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 751 QUAIL JOHN RD | ||||||||
Address2: |   | ||||||||
City: | EAST THETFORD | ||||||||
State: | VT | ||||||||
PostalCode: | 050439615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027854417 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | RANDOLPH | ||||||||
State: | VT | ||||||||
PostalCode: | 050601330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027284466 | ||||||||
FaxNumber: | 8027284197 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 042-0009705 | VT | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 38694 | 01 | VT | BLUE CROSS | OTHER | 0108291Y0VT01 | 01 | VT | ANTHEM NH | OTHER | 2002983 | 01 | VT | CIGNA | OTHER | 0VN1795 | 05 | VT |   | MEDICAID |