Basic Information
| Provider Information | |||||||||
| NPI: | 1972646602 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN MOUNTAIN ENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1352 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054951352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025247100 | ||||||||
| FaxNumber: | 8025247021 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 CREST RD | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054789503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025271976 | ||||||||
| FaxNumber: | 8025270865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | DARIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8025271976 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1008985 | 05 | VT | MEDICAID |