Basic Information
| Provider Information | |||||||||
| NPI: | 1598278137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREEN MOUNTAIN PLASTIC AND RECONSTRUCTIVE SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 354 MOUNTAIN VIEW DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLCHESTER | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054465988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028640192 | ||||||||
| FaxNumber: | 8028604919 | ||||||||
| Practice Location | |||||||||
| Address1: | 354 MOUNTAIN VIEW DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLCHESTER | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054465988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028640192 | ||||||||
| FaxNumber: | 8028604919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2017 | ||||||||
| LastUpdateDate: | 11/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | LAUB | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8025989619 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0105X | 42-0008887 | VT | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 208200000X | 42-0008887 | VT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | OVN1072 | 05 | VT | MEDICAID |