Healthcare Provider Details

I. General information

NPI: 1558885988
Provider Name (Legal Business Name): GREEN MOUNTAIN INTERNAL MEDICINE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 S WILLIAMS ST
BURLINGTON VT
05401-3486
US

IV. Provider business mailing address

28 S WILLIAMS ST
BURLINGTON VT
05401-3486
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-7080
  • Fax:
Mailing address:
  • Phone: 802-864-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042-0010014
License Number StateVT

VIII. Authorized Official

Name: MS. DEBORAH CAISE
Title or Position: OFFICE MANAGER
Credential:
Phone: 802-864-7080