Healthcare Provider Details

I. General information

NPI: 1013934835
Provider Name (Legal Business Name): SALLY HERSCHORN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3592
  • Fax: 802-847-4822
Mailing address:
  • Phone: 802-847-3592
  • Fax: 802-847-4822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0420007509
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: