Healthcare Provider Details

I. General information

NPI: 1346459153
Provider Name (Legal Business Name): VERMONT INTERVENTIONAL SPINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 MOUNTAIN VIEW DR
COLCHESTER VT
05446-5985
US

IV. Provider business mailing address

356 MOUNTAIN VIEW DR SUITE 200
COLCHESTER VT
05446
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-9798
  • Fax:
Mailing address:
  • Phone: 802-655-9798
  • Fax: 802-655-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TERE F BERRY
Title or Position: OFFICE MANAGER
Credential: MD
Phone: 802-655-9798