Basic Information
| Provider Information | |||||||||
| NPI: | 1316273279 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DUTTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | ATT: CVMC FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024854161 | ||||||||
| FaxNumber: | 8024854163 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 PAINE MOUNTAIN DR | ||||||||
| Address2: | GREEN MOUNTAIN FAMILY PRACTICE | ||||||||
| City: | NORTHFIELD | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056635791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024854161 | ||||||||
| FaxNumber: | 8024854163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2009 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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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 | 207Q00000X | ML 60107751 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 042.0013288 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ML 60107751 | 01 | WA | PHYSICIAN AND SURGEON RESIDENCY LICENSE | OTHER |