Basic Information
| Provider Information | |||||||||
| NPI: | 1497710065 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN MOUNTAIN ORTHOPAEDIC SURGERY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | BUILDING A, SUITE 2-2 | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056029516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022292663 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | BUILDING A, SUITE 2-2 | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056029516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022292663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | MERIAM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8022292663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 6499280001 | VT | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 6499280001 | 01 | VT | MEDICARE PTAN | OTHER | 30216639 | 05 | NH | MEDICAID | 1009345 | 05 | VT | MEDICAID |