Healthcare Provider Details

I. General information

NPI: 1073617783
Provider Name (Legal Business Name): GREEN MOUNTAIN PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MAIN STREET SUITE 1
BENNINGTON VT
05201
US

IV. Provider business mailing address

901 MAIN STREET SUITE 1
BENNINGTON VT
05201
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-6057
  • Fax: 802-447-1348
Mailing address:
  • Phone: 802-442-6057
  • Fax: 802-447-1348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateVT

VIII. Authorized Official

Name: DR. JUDY K ORTON
Title or Position: PRESIDENT DIRECTOR
Credential: MD PA
Phone: 802-442-6057