Basic Information
| Provider Information | |||||||||
| NPI: | 1275585689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVIE | ||||||||
| FirstName: | CLARENCE | ||||||||
| MiddleName: | SHERMAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472415 | ||||||||
| FaxNumber: | 8028472965 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | WP-2 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472415 | ||||||||
| FaxNumber: | 8028472965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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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 | 207L00000X | 032-0000512 | VT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1013468 | 05 | VT | MEDICAID | VN417801 | 01 | VT | MEDICARE | OTHER |