Healthcare Provider Details

I. General information

NPI: 1811948847
Provider Name (Legal Business Name): STEPHEN S KORNBLUTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 ROUTE 30 N
BOMOSEEN VT
05732-9647
US

IV. Provider business mailing address

71 ALLEN STREET SUITE 403
RUTLAND VT
05701-4570
US

V. Phone/Fax

Practice location:
  • Phone: 802-468-5641
  • Fax: 802-468-2923
Mailing address:
  • Phone: 802-772-4414
  • Fax: 802-772-7973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number153606
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0420011399
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: