Basic Information
| Provider Information | |||||||||
| NPI: | 1295140754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF VERMONT MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UVM MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 526 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054020526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028471882 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1060 HINESBURG RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SOUTH BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054037628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028471777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRUMSTED | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8028471882 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1023456 | 05 | VT | MEDICAID |