Healthcare Provider Details

I. General information

NPI: 1205821220
Provider Name (Legal Business Name): VIRGINIA C BRACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 CLIFF ST
NORWICH VT
05055-9412
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5000
  • Fax:
Mailing address:
  • Phone: 802-649-3891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042-0010058
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: