Healthcare Provider Details

I. General information

NPI: 1962728402
Provider Name (Legal Business Name): LYLE P. GERETY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE 111 COLCHESTER AVE.
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE UVM MEDICAL CENTER - DEPT. OF ANESTHESIOLOGY
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2415
  • Fax: 802-847-5324
Mailing address:
  • Phone: 802-847-2415
  • Fax: 802-847-5324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA130375
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number042.0013227
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: