Healthcare Provider Details

I. General information

NPI: 1689949968
Provider Name (Legal Business Name): RUTLAND REGION COLLABORATIVE ACO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
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

275 ROUTE 30 N
BOMOSEEN VT
05732-9647
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHAEL GARDNER
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 802-773-3386