Basic Information
Provider Information | |||||||||
NPI: | 1255380432 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THAYER | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 32 PITKIN ST | ||||||||
Address2: |   | ||||||||
City: | BURLINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 054015120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8022384972 | ||||||||
FaxNumber: | 8025247021 | ||||||||
Practice Location | |||||||||
Address1: | 4178 HIGHBRIDGE RD | ||||||||
Address2: |   | ||||||||
City: | GEORGIA | ||||||||
State: | VT | ||||||||
PostalCode: | 05454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8025249595 | ||||||||
FaxNumber: | 8025242867 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2006 | ||||||||
LastUpdateDate: | 03/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD22764 | ME | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QA0401X | 042000 | VT | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207QA0401X | MD22764 | ME | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | 0420008222 | VT | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0009919 | 05 | VT |   | MEDICAID | 080176413 | 01 | VT | RAIL ROAD MEDICARE | OTHER |