Healthcare Provider Details

I. General information

NPI: 1316032188
Provider Name (Legal Business Name): MARY CUSHMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

264 LITTLEFIELD DR
SHELBURNE VT
05482-6357
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-8400
  • Fax: 802-847-1258
Mailing address:
  • Phone: 802-985-1107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number0420008994
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: