Healthcare Provider Details

I. General information

NPI: 1376660977
Provider Name (Legal Business Name): TERESA ANN FAMA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER ROAD MOB-B SUITE 2-3
BERLIN VT
05602-9522
US

IV. Provider business mailing address

PO BOX 547 CENTRAL VERMONT MEDICAL CENTER INC-FINANCE DEPT
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-225-1750
  • Fax: 802-225-1733
Mailing address:
  • Phone: 802-225-1750
  • Fax: 802-225-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number0420011411
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number060-0002965
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: