Basic Information
| Provider Information | |||||||||
| NPI: | 1942275771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOELLA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 905 | ||||||||
| Address2: | NORTHEASTERN VT REGIONAL HOSPITAL | ||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058190905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027488141 | ||||||||
| FaxNumber: | 8027484098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1315 HOSPITAL DR | ||||||||
| Address2: | NORTHEASTERN VT REGIONAL HOSPITAL | ||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027488141 | ||||||||
| FaxNumber: | 8027484098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200876 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 042-0013372 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10020809 | 01 | NY | CDPHP | OTHER | 000401661005 | 01 | NY | BLUE SHIELD | OTHER | 040426007236 | 01 | NY | FIDELIS | OTHER | 000000042317 | 01 | NY | GHI | OTHER | 9X3071 | 01 | NY | EMPIRE BLUE CROSS | OTHER | 958301 | 01 | NY | MVP | OTHER | 01592667 | 05 | NY | MEDICAID | 43790 | 01 | NY | GHI HMO | OTHER | 5968600 | 01 | NY | AETNA | OTHER |