Basic Information
| Provider Information | |||||||||
| NPI: | 1679511711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STITELMAN | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ZIEBUR | ||||||||
| OtherFirstName: | MARTHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 BLAIR PARK RD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054957586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724342 | ||||||||
| FaxNumber: | 8028720282 | ||||||||
| Practice Location | |||||||||
| Address1: | 600BLAIR PARK RD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724342 | ||||||||
| FaxNumber: | 8028720282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
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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 | 207QG0300X | 42-0008683 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 378491 | 01 | MOHAWK VALLEY HEALTH PLAN | OTHER | 00018950 | 01 | VT | BLUE CROSS BLUE SHIELD | OTHER | 0VN0578 | 05 | VT | MEDICAID |