Basic Information
| Provider Information | |||||||||
| NPI: | 1619266624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLETCHER ALLEN HEALTH CARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAHC RADIATION ONCOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1063 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054021063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028471882 | ||||||||
| FaxNumber: | 8028476254 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028470000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2011 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | DESHAIES | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8028475911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLETCHER ALLEN HEALTH CARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 748 | VT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.