Healthcare Provider Details

I. General information

NPI: 1427255538
Provider Name (Legal Business Name): GREEN MOUNTAIN NEUROLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 NORTH ST SUITE 205
PITTSFIELD MA
01201-4147
US

IV. Provider business mailing address

777 NORTH ST SUITE 205
PITTSFIELD MA
01201-4147
US

V. Phone/Fax

Practice location:
  • Phone: 413-395-7517
  • Fax: 413-395-7518
Mailing address:
  • Phone: 413-395-7517
  • Fax: 413-395-7518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number71916
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number71916
License Number StateMA

VIII. Authorized Official

Name: DR. ALEXANDER S KLOMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 413-395-7517