Healthcare Provider Details

I. General information

NPI: 1518059039
Provider Name (Legal Business Name): GREEN MOUNTAIN RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER RD CENTRAL VERMONT HOSPITAL
BERLIN VT
05602-9516
US

IV. Provider business mailing address

PO BOX 660
MORETOWN VT
05660-0660
US

V. Phone/Fax

Practice location:
  • Phone: 802-371-4249
  • Fax:
Mailing address:
  • Phone: 802-496-5252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT DALE JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 802-371-4249