Basic Information
| Provider Information | |||||||||
| NPI: | 1386629202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 289 COUNTY RD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050899000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026747300 | ||||||||
| FaxNumber: | 8026747314 | ||||||||
| Practice Location | |||||||||
| Address1: | 289 COUNTY RD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050899000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026747300 | ||||||||
| FaxNumber: | 8026747314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 06/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 042-0011035 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 0420011035 | VT | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1012052 | 05 | VT | MEDICAID |