Basic Information
| Provider Information | |||||||||
| NPI: | 1508963596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAROL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | BETTY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 FAIFIELD ST. | ||||||||
| Address2: | |||||||||
| City: | ST. ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025241223 | ||||||||
| FaxNumber: | 8025241095 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 FAIFIELD ST. | ||||||||
| Address2: | |||||||||
| City: | ST. ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025241223 | ||||||||
| FaxNumber: | 8025241095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 52047141205 | UT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083X0100X | 162694-1 | NY | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 2083X0100X | 042.0013949 | VT | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.